New Mexico Register / Volume
XXXIII, Issue 6 / March 22, 2022
This is an amendment to 8.314.5 NMAC,
Sections 7 through1, 14 through 18 and 20, effective 4/1/2022.
8.314.5.7 DEFINITIONS:
A. Activities of daily living (ADLs): Basic personal everyday activities
that include bathing, dressing, transferring (e.g., from bed to chair),
toileting, oral care, mobility and eating.
B. Adult:
An individual who is 18 years of age or older.
C. Authorized
representative: An individual designated
by the eligible recipient or [his or her] their guardian, if
applicable, to represent the eligible recipient and act on [his or her] their
behalf. The authorized representative
must provide formal documentation authorizing [him or her] them
to access the identified case information for this specific purpose. An authorized representative may be, but need
not be, the eligible recipient’s guardian or attorney.
D. 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.
E. Clinical
Documentation: Sufficient
information and documentation that demonstrates the request for initial
and ongoing developmental disabilities
waiver (DDW) services is necessary and appropriate based on the service
specific DDW clinical criteria established by the department of health (DOH)
developmental disabilities support division (DDSD) for adult recipients
excluding class members of Walter Stephen Jackson, et al vs. Fort Stanton
Hospital and Training School et. al, (757 F. Supp. 1243 DNM 1990). [Examples of clinical documentation
include but are not limited to: the therapy service prior authorization request
(TSPAR), behavioral support consultation prior authorization request (BSCPAR),
intense medical living service (IMLS) parameter tool, electronic comprehensive
health assessment tool (e-Chat), assessments, clinical notes, progress notes,
interdisciplinary team (IDT) meeting minutes, letters from physicians or
ancillary service providers that provide sufficient clinical information that
demonstrates the need for requested services, etc. Any relevant supporting information and
documentation is acceptable and will be considered by the outside reviewer.]
Examples of clinical documentation include but are not limited to: the DDW therapy documentation form (TDF),
intensive medical living supports (IMLS) and adult nursing services parameter
tools, electronic comprehensive health assessment tool (e-Chat), all other
assessments, clinical notes, progress notes, interdisciplinary team (IDT)
meeting minutes, letters or reports from physicians or ancillary service
providers that provide sufficient clinical information that demonstrates the
need for requested services, etc. Any
relevant supporting information and documentation is acceptable and will be
considered by the outside reviewer.
F. Clinical
justification: Information and
documentation that justifies the need for services based on the eligible
recipient’s assessed need and the DDW clinical criteria. Based on assessed need, the justification
must:
(1) meet
the eligible recipient’s clinical, functional, physical, behavioral or
habilitative needs;
(2) promote and afford support to the eligible recipient for [his or her]
their greater independence and to maintain current level of function
or minimize risk of further decline; or
(3) contribute
to and support the eligible recipient’s efforts to remain in the community; to
contribute and be engaged in [his or her] their community, and to
reduce [his or her] their risk of institutionalization; and
(4) address
the eligible recipient’s physical health, behavioral, and social
support needs (not including financial support) that arise as a result of [his
or her] 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).
G. DDW clinical criteria: A set of criteria established by the DOH/DDSD
that is applied by an outside reviewer to each DDW service when a DDW service
is requested for [adult] recipients excluding class members of Walter
Stephen Jackson, et al vs. Fort Stanton
Hospital and Training School et. al, (757 F. Supp. 1243 DNM 1990).
H. Electronic visit verification (EVV): A
telephone and computer-based system that electronically verifies the occurrence
of selected services, as required by the 21st Century CURES Act. The EVV system verifies the occurrence of
authorized service visits electronically by documenting the precise time and
location where service delivery visit begins and ends. EVV is implemented according to federal
requirements and timelines. The 21st
Century CURES Act requires EVV for personal care services (PCS), defined as
services that provide assistance with activities of daily living (ADLs) or instrumental
activities for daily living (IADLs) effective January 1, 2020 and for home
health services effective January 1, 2023.
[H.] I. Individual
service plan (ISP): [A
person-centered plan for an eligible recipient that includes his or her needs,
functional levels, intermediate and long range outcomes for achieving his or
her goals and specifies responsibilities for the eligible recipient’s support
needs. The ISP determines the services
allocated to the eligible recipient.] A person-centered plan for an
eligible recipient that includes their needs, functional levels, intermediate
and long-range outcomes for achieving their goals and specifies
responsibilities for the eligible recipient’s support needs. The ISP enables and assists the recipient to
identify and access a personalized mix of paid waiver and non-paid services and
supports that assists them to achieve personally defined outcomes in the
community.
[I.] J. Outside reviewer: An
independent [third party] third-party assessor who has a contract
with the DOH to conduct clinical reviews of all
requested DDW services. The outside
reviewer will make a written determination on whether the requested supports
are clinically justified and will recommend whether the eligible recipient’s
requested ISP and budget should be approved or denied. The decision of the outside reviewer to
approve any requested service is binding on the state. However, the state may agree to overturn a
decision to deny requested services.
[J.] K. 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 DDW program and DDW service
provider’s work with individuals with I/DD.
The process is designed to identify the strengths, capacities,
preferences, needs, and desired outcomes of the recipient. The process may include other persons, freely
chosen by the individual, 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 recipient
to identify and access a personalized mix of paid and non-paid services and
supports that assists him or her to achieve personally defined outcomes in the
community.]
[K.] L. Waiver: Permission from the centers for medicaid and
medicare services (CMS) to cover supports for a particular population or
service not ordinarily allowed.
[L.] M. Young Adult: An
individual between the ages of 18 through 20 years of age who is allocated to
the DDW and is receiving specific services as identified in the DOH/DDSD
standards [and policies]. An
individual under age 21 is eligible for medical services funded by [his or
her] their medicaid providers under EPSDT. Upon the individual’s 21st
birthday, [he or she is] they are considered to be an adult
recipient of DDW services.
[8.314.5.7 NMAC -
Rp. 8.314.5.7 NMAC, 12/1/2018; A, 4/1/2022]
8.314.5.8 [RESERVED] SAFEGUARDS
CONCERNING RESTRAINTS, RESTRICTIONS AND SECLUSION:
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;
(k) privacy violations;
(l) restricting exit from home with
locks on windows or doors;
(m) application of water mist; and
(n) application of noxious taste, smell,
or skin agents; etc.
(2) Use of restrictive interventions
must be documented in the individual’s positive behavior support plan or behavioral
crisis intervention plan or risk management plan and must be reviewed by the
human rights committee prior to implementation.
(3) Chemical
restraint is defined as the administration of medication at a dose or frequency
to intentionally and exclusively preclude behavior without identifying an
underlying anxiety, fear or severe emotional distress or other symptoms of
psychiatric/emotional disturbance to be eased, managed or treated. The administration may be regularly scheduled
or on a pro re nata (PRN), or “as needed” basis. The use of chemical restraints is prohibited.
(4) The administration of PRN
psychotropic medication is allowed when prescribed in advance by the
prescribing professional. A PRN
psychotropic medication plan is a collaborative document that outlines the
behavioral indications for using the medication. A human rights committee must approve use of
PRN psychotropic medication prior to its implementation and the procedures that
DSP must use to gain approval for its implementation.
(5) Mechanical restraints are defined as
the use of a physical device to restrict the individual’s capacity for desired
or intended movement including movement or normal function of a portion of
their body. The use of mechanical
restraints is prohibited.
(6) Use of any emergency physical
restraints must be written into a behavioral crisis intervention plan only and
approved by a human rights committee prior to its use. Personal restraints (i.e. emergency physical
restraints) are used as a last resort, only when other less intrusive
alternatives have failed and under limited circumstances that include
protecting an individual or others from imminent, serious physical harm, or to
prevent or minimize any physical or emotional harm to the individual. Staff must be trained in both nonphysical and
physical interventions.
(7) Any individual for whom the use of
emergency physical restraints or PRN psychotropic medications is allowed is
required to have a positive behavioral supports assessment, positive behavior
support plan, and a behavioral crisis intervention plan or PRN psychotropic
medication plan completed by a behavior support consultant in conjunction with
the individual’s agency nurse and interdisciplinary team.
(8) Ethical, medical or behavioral concerns,
use of live or recorded video monitoring/observational systems, and resolution
of plans contested on the individual team or provider agency level in local
human rights committees are heard and resolved in a statewide and state
coordinated super human rights committee.
[8.314.5.8 NMAC, N,
4/1/2022]
8.314.5.9 DEVELOPMENTAL DISABILITIES HOME
AND COMMUNITY-BASED SERVICES WAIVER: 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;
[F.]
G. optimizes individual
initiative, autonomy and independence in making life choices;
[G.] H. provides an opportunity to seek competitive
employment;
[H.] I. provides individuals an
option to choose a private unit in a residential setting; and
[I.] J. facilitates choice of services and who provides them.
[8.314.5.9 NMAC -
Rp, 8.314.5.9 NMAC, 12/1/2018; A, 4/1/2022]
8.314.5.10 Eligible
Providers:
A. Health
care to [MAP] 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 [MAP]
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, [his
or her] 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; and
(3) comply
with all training requirements as specified by DOH/DDSD; and
(4) have received written notification from DOH that [he or she does]
they do not have a disqualifying conviction after submitting to the
caregiver criminal history screening (CCHS);
(5) [does
not provide any direct support services through any other type of 1915 (c) HCBS
waiver program;] 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.
E. Qualifications of respite provider agency: A respite provider agency must comply and
ensure that all direct support personnel, whether subcontractors or employees,
comply with 8.314.5.10 NMAC. In
addition, respite provider agencies and direct support personnel must:
(1) comply
with all training requirements as specified by DOH;
(2) have
and maintain documentation of current cardiopulmonary resuscitation (CPR) and
first aid certification; [and]
(3) have
written notification from DOH that [he or she does] they do not
have a disqualifying conviction after submitting to the CCHS; and
(4) comply with all EVV requirements as
defined by the 21st Century CURES Act and implemented by MAD
including but not limited to documenting service
provision using the approved EVV system.
F. Qualifications of
adult nursing provider agencies:
Adult nursing provider agencies must ensure all subcontractors or
employees, including nurses, comply with DOH DDW service definitions, DDW
service standards, applicable NMAC rules, MAD billing instructions, utilization
review instructions, and supplements, and applicable federal and state laws,
rules and statutes. Direct nursing
services shall be provided by a New Mexico licensed RN or licensed practical
nurse (LPN), have a minimum of one year experience as a licensed nurse,
and must comply with all aspects of the New Mexico Nursing Practice Act,
including supervision and delegation requirements of specific nursing function
and 8.314.5.10 NMAC.
G. Qualifications of therapy provider agency: A therapy provider agency must comply and
ensure that each of its therapists including physical therapists (PT),
occupational therapists (OT), and speech therapists (SLP), physical therapy
assistants (PTA), and certified occupational therapy assistants (COTA), whether
a subcontractor or employee complies with 8.314.5.10 NMAC.
H. Qualifications for [community]
living supports provider agency:
Living supports consist of family living, supported living, and intensive
medical living [services] supports. A living supports provider agency must comply
with the accreditation policy and all requirements set forth by the DOH, DDW
service definitions, all requirements outlined in the DDW service standards and
the applicable NMAC rules. A living
supports provider agency must ensure that all direct support personnel meet all
qualifications set forth by DOH, DDW service standards, and applicable NMAC
rules.
(1) A
living supports provider agency and direct support personnel must:
(a) comply
with all training requirements as specified by DOH;
(b) have
and maintain documentation of current CPR and first aid certification; and
(c) have
written notification from DOH that [he or she does] they do not
have a disqualifying conviction after submitting to the CCHS.
(2) A
family living provider agency must ensure that all direct support personnel,
whether a subcontractor or employee, meet all qualifications set forth by DOH
and the DDW service standards and the applicable NMAC rules. Legal guardians who are also natural or
adoptive family members who meet the DOH/DDSD requirements and are approved to
provide family living services may be paid for providing services.
A family living
provider agency must employ or subcontract with at least one registered or
licensed dietician or licensed nutritionist.
A family living provider agency must also be an adult nursing services
provider and must employ or subcontract with at least one licensed RN; employ
or subcontract with at least one additional nurse for on call services and
comply with the New Mexico Nurse Practice Act, including supervision and
delegation requirements of specific nursing functions. The number of nurses (RNs and LPNs) must be
sufficient to meet the routine and on call health care needs of the
individuals. [The] Both the direct support
personnel employed by or subcontracting with the provider agency and the
physical home setting must be approved through a home study completed prior
to the initiation of services, revised with any change in family composition,
move to a new home, or other significant event and periodically
thereafter as required of the provider agency.
(3) A
supported living provider agency must ensure that all direct support personnel
meet all qualifications set forth by DOH and the applicable NMAC rules and the
DDW service standards. A supported
living provider agency must employ or subcontract with at least one registered
or licensed dietician or licensed nutritionist. The number of RD/LDs employed
or under contract must be sufficient to meet the routine nutritional needs of
the individuals. They must employ or subcontract with at least one licensed
RN, employ or subcontract with at least one additional nurse for on call and
services, and comply with the New Mexico Nurse Practice [Practicing]
Act, including supervision and delegation requirements of specific nursing
functions. The number of nurses (RNs
and LPNs) must be sufficient to meet the routine and on call health care needs
of the individuals.
(4) An
intensive medical living supports provider agency must employ or subcontract
with at least one registered or licensed dietician or licensed
nutritionist. The number of RD/LDs
employed or under contract must be sufficient to meet the routine nutritional
needs of the individuals. They must
employ or subcontract with at least one New Mexico licensed RN who must
have a minimum of one year of [supervised] nursing experience employ
or subcontract with at least one additional nurse for on call services and
comply with the New Mexico Nursing Practice Act including supervision and
delegation requirements of specific nursing functions. The number of nurses (RNs and LPNs) must be
sufficient to meet the routine and on call health care needs of the individuals. [An intensive medical living supports
provider agency must comply with and ensure RNs, whether subcontractors or
employees, comply with 8.314.5.10 NMAC.
An intensive medical living supports provider agency and direct support
personnel must:
(a) comply
with all training requirements as specified by DOH;
(b) have
and maintain documentation of current CPR and first aid certification; and
(c) have
written notification from DOH that he or she does not have a disqualifying
conviction after submitting to the CCHS.]
I. Qualifications of a customized community
supports provider agency: A
customized community supports provider agency must comply with and ensure that
all direct support personnel comply with 8.314.5.10 NMAC. A customized community supports provider
agency and direct support personnel must:
(1) comply
with all training requirements as specified by DOH;
(2) have
and maintain documentation of current CPR and first aid certification; and
(3) have
written notification from DOH that [he or she does] they do not
have a disqualifying conviction after submitting to the CCHS.
J. Qualifications of a community integrated
employment provider agency: A
community integrated employment provider agency must comply with and ensure
that all direct support personnel comply with 8.314.5.10 NMAC. A community integrated employment provider
agency and direct support personnel must:
(1) comply
with all training requirements as specified by DOH;
(2) have
and maintain documentation of current CPR and first aid certification; and
(3) have
written notification from DOH that [he or she does] they do not
have a disqualifying conviction after submitting to the CCHS.
K. Qualifications of a behavioral support
consultation provider agency: A behavioral
support consultation provider agency must comply with and ensure that all
behavioral support consultants, whether subcontractors or employees, comply
with 8.314.5.10 NMAC.
(1) A
provider of behavioral support consultation services must be currently licensed
in one of the following professions and maintain that licensure with the
appropriate RLD board or licensing authority:
(a) a
licensed clinical mental health counselor (LMHC), or
(b) a
licensed [clinical] psychologist; or
(c) a
licensed psychologist associate, (masters or Ph.D. level); or
(d) a
licensed independent social worker (LISW) or a licensed clinical social worker
(LCSW); or
(e) a
licensed master social worker (LMSW); or
(f) a
licensed professional clinical mental health counselor (LPCC); or
(g) a
licensed marriage and family therapist (LMFT); or
(h) a
licensed [practicing] professional art therapist (LPAT); or
(i) Other related licenses and
qualifications may be considered with DOH’s prior written approval.
(2) Providers
of behavioral support consultation services must have a minimum of one year of
experience working with individuals with intellectual or developmental
disabilities.
(3) Behavioral
support consultation providers must participate in training in accordance with
the DOH/DDSD training policy.
L. Qualifications
of a nutritional counseling provider agency: A nutritional counseling provider agency must
comply with and ensure that all nutritional counseling providers, whether
subcontractors or employees comply with 8.314.5.10 NMAC. In addition, a nutritional counseling
provider must be registered as a dietitian or a licensed nutritionist by
the commission on dietetic registration of the American dietetic association
and be licensed by RLD as a nutrition counselor.
M. Qualifications of an environmental
modification provider agency: An
environmental modification contractor and [his or her] their
subcontractors and employees must be bonded, licensed by RLD, and authorized by
DOH to complete the specified project.
An environmental modification provider agency must comply with
8.314.5.10 NMAC. All services shall be
provided in accordance with applicable federal, state and local building codes.
N. Qualifications of a crisis supports
provider agency: A crisis supports
provider agency must comply with and must ensure that direct support personnel,
whether subcontractors or employees, comply with 8.314.5.10 NMAC. In addition, a crisis supports provider
agency and direct support personnel must:
(1) comply
with all training requirements as specified by DOH;
(2) have
and maintain documentation of current CPR and first aid certification; and
(3) have
written notification from DOH that [he or she does] they do not
have a disqualifying conviction after submitting to the CCHS.
[ O. Qualifications for a non-medical
transportation provider agency: A
non-medical transportation provider agency must comply with 8.314.5.10
NMAC. In addition, a non-medical
transportation provider agency and direct support personnel must:
(1) comply
with all training requirements as specified by DOH;
(2) have
and maintain documentation of current CPR and first aid certification; and
(3) have
written notification from DOH that he or she does not have a disqualifying
conviction after submitting to the CCHS.
P. Qualifications of a
supplemental dental care provider agency:
A supplemental dental care provider agency must comply with 8.314.5.10
NMAC. A supplemental dental care
provider must contract with a New Mexico licensed dentist and dental hygienist
who are licensed by RLD. The
supplemental dental care provider will ensure that a RLD licensed dentist
provides the oral examination; ensure that a RLD licensed dental hygienist
provides all routine dental cleaning services; demonstrate fiscal solvency; and
function as a payee for the service.]
Q. Qualifications of an assistive technology
purchasing agent provider and: An
assistive technology purchasing agent provider and agency must comply with
8.314.5.10 NMAC, demonstrate fiscal solvency and function as a payee for this
service.
R. Qualifications of an independent living
transition service provider agency:
An independent living transition
service provider agency must comply with
8.314.5.10 NMAC, demonstrate fiscal solvency and function as a payee for this
service.
S. Qualifications of a personal support
technology/on-site response service provider agency: Personal support technology/on-site response
service provider agencies must comply with 8.314.5.10 NMAC. In addition, personal support
technology/on-site response service provider agencies must comply with all
laws, rules, and regulations of the federal communications commission (FCC) for
telecommunications.
T. Qualifications of a preliminary risk
screening and consultation related to inappropriate sexual behavior (PRSC) provider agency: A PRSC provider agency must comply with
8.314.5.10 NMAC and all training requirements as specified by DOH. Additionally, the PRSC provider agency must
subcontract with or employ the risk evaluator, who at a minimum must be:
(1) an
RLD independently licensed behavioral health practitioner, such as an LPCC,
LCSW, LMFT, LISW, or a psychologist; or
(2) a
practitioner who holds a master’s or doctoral degree in a behavior health
related field from an accredited college or university.
U. Qualifications of a socialization and
sexuality education provider agency:
A socialization and sexuality education provider agency must comply with
8.314.5.10 NMAC. A provider agency must
be approved by the DOH, bureau of behavioral support (BBS) as a socialization
and sexuality education provider, and must meet training requirements as
specified by DOH. In addition, a
socialization and sexuality education provider agency must employ or contract
with a provider who has one of the following qualifications for rendering the
service:
(1) a
master's degree or higher in psychology;
(2) a
master's degree or higher in counseling;
(3) a
master's degree or higher in special education;
(4) a
master's degree or higher in social work;
(5) a
master's degree or higher in a related field;
(6) a
RN or LPN;
(7) a
bachelor's degree in special education or a related field such as psychology or
social work;
(8) a
certification in special education; or
(9) a
New Mexico level three recreational therapy instructional support provider
certification.
V. Qualifications of a customized in-home supports provider agency: A
customized in-home supports provider agency must comply with and ensure that
direct support personnel, whether subcontractors or employees, comply with
8.314.5.10 NMAC. A customized in-home
supports provider agency and direct support personnel must:
(1) comply
with all training requirements as specified by DOH;
(2) have
and maintain documentation of current CPR and first aid certification; and
(3) have
written notification from DOH that he or she does not have a disqualifying
conviction after submitting to the CCHS.]
O. Qualifications for a non-medical transportation provider
agency: A non-medical transportation
provider agency must comply with 8.314.5.10 NMAC. In addition, a non-medical transportation
provider must have a business license and drivers must have a valid driver’s
license and not have a disqualifying conviction after submitting to the
CCHS. Must have written notification
from DOH that they do not have a disqualifying conviction after submitting to
the CCHS.
P. Qualifications of an assistive technology provider
agency: An assistive technology
purchasing agent provider and agency must comply with 8.314.5.10 NMAC,
demonstrate fiscal solvency when functioning as a payee for this service. Assistive technology providers may also be
the direct vendors of approved technology.
Q. Qualifications of an independent living transition
service provider agency: An
independent living transition service provider agency must comply with
8.314.5.10 NMAC, demonstrate fiscal solvency and function as a payee for this
service.
R. Qualifications of a remote personal support technology
provider agency: Remote personal
support technology provider agencies must comply with 8.314.5.10 NMAC. This includes having a current business
license and must demonstrate fiscal solvency and function as a payee of
services. In addition, remote personal
support technology provider agencies must comply with all laws, rules, and
regulations of the federal communications commission (FCC) for
telecommunications.
S. Qualifications of a preliminary risk screening and
consultation (PRSC) related to inappropriate sexual behavior provider agency: A PRSC provider agency must comply with
8.314.5.10 NMAC and all training requirements as specified by DOH. Additionally, the PRSC provider agency must
subcontract with or employ the evaluator, who at a minimum must be:
(1) an
RLD independently licensed behavioral health practitioner, such as an LPCC,
LCSW, LMFT, LISW, or a psychologist; or
(2) a
practitioner who holds a master’s or doctoral degree in a behavior health
related field from an accredited college or university.
T. Qualifications of
a socialization and sexuality education provider agency: A socialization and sexuality education
provider agency must comply with 8.314.5.10 NMAC. A provider agency must be approved by the
DOH, bureau of behavioral support (BBS) as a socialization and sexuality
education provider and must meet training requirements as specified by
DOH. In addition, a socialization and
sexuality education provider agency must employ or contract with a provider who
has one of the following qualifications for rendering the service:
(1) a
master's degree or higher in psychology;
(2) a
master's degree or higher in counseling;
(3) a
master's degree or higher in special education;
(4) a
master's degree or higher in social work;
(5) a
master's degree or higher in a related field;
(6) a
RN or LPN;
(7) a
bachelor's degree in special education or a related field such as psychology or
social work;
(8) a
certification in special education;
(9) a New Mexico level three recreational
therapy instructional support provider license; or
(10) a certified therapeutic recreation
therapist (CTRS) obtained through the national council for therapeutic
recreation.
U. Qualifications of a customized in-home supports provider
agency: A customized in-home
supports provider agency must comply with and ensure that direct support
personnel, whether subcontractors or employees, comply with 8.314.5.10
NMAC. Legal guardians who are also
natural or adoptive family members, relatives, or natural family members that
meet the DOH/DDSD requirements and are approved to provide customized in-home
supports may be paid for providing services.
A customized in-home supports provider agency and direct support
personnel must:
(1) comply
with all training requirements as specified by DOH;
(2) have
and maintain documentation of current CPR and first aid certification; and
(3) have
written notification from DOH that they do not have a disqualifying conviction
after submitting to the CCHS.
(4) comply with all EVV requirements as
defined by the 21st Century CURES Act and implemented by MAD
including but not limited to documenting service
provision using the approved EVV system.
V. Qualifications of a supplemental
dental care provider agency: A supplemental dental care
provider agency must comply with 8.314.5.10 NMAC. A supplemental dental care provider must
contract with a New Mexico licensed dentist and dental hygienist who are
licensed by RLD. The supplemental dental
care provider will ensure that a RLD licensed dentist provides the oral
examination; ensure that a RLD licensed dental hygienist provides all routine
dental cleaning services; demonstrate fiscal solvency; and function as a payee
for the service.
[8.314.5.10 NMAC -
Rp, 8.314.5.10 NMAC, 12/1/2018; A, 4/1/2022]
8.314.5.11 Provider Responsibilities:
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 of a DDW provider shall not serve as guardian for a person served by that agency, except when related by affinity or consanguinity (45-5-31(1) A 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.
D. Case management agencies are required to mitigate real or perceived conflict of interest issues by adhering to, at minimum the following requirements. Case managers who are contracted under the DDW are identified as agents who are responsible for the development of the ISP.
(1) Case management agency owners and individually employed or contracted case managers may not:
(a) be related by blood or affinity to
the person supported, or to any paid caregiver of the individual
supported. Following formal
authorization from DDSD, a case manager may provide family living services or
respite to their own family member; [or to an individual who receives case
management services from another provider;]
(b) have material financial interest in any entity that is paid to provide DDW or mi via services. A material financial interest is defined as anyone who has, directly or indirectly, any actual or potential ownership, investment, or compensation arrangement;
(c) be empowered to make financial or health related decisions for individuals on their caseload;
(d) be related by blood or affinity to any
DDW service provider for individuals on their caseload. Providers are identified as providers of
living care arrangements, community inclusion services, mi via consultants, mi
via vendors, BSC’s and therapist.
[ (e) hold a caseload on mi via and DDW
simultaneously.]
(2) A case management provider agency may not:
(a) be a provider agency for any other DDW service;
(b) provide guardianship services to an individual receiving case management services from that same agency;
(3) A case manager or director of a case management provider agency may not:
(a) serve on the board of directors of any DDW provider agency;
(4) [Case management provider agencies
must disclose to both DDSD and to people supported by their agency any familial
relationships between employees/subcontract case managers and providers of
other DDW services.] Case management provider agencies must disclose to
both DDSD and the people supported by their agency any familial relationships
between employees or subcontract case managers and providers of other DDW
services.
(5) Case management provider agency staff and subcontractors must maintain independence and avoid all activity which could be perceived as a potential conflict of interest.
[8.314.5.11 NMAC - Rp, 8.314.5.11 NMAC,
12/1/2018; A, 4/1/2022]
8.314.5.14 DDW Covered Waiver Services for identified
population under 18 years of age: 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: The child’s level of care assessment is used to determine
the annual resource allotment (ARA) within the under 18 years of age
category. The service options funded
within the ARA allow the family of an eligible recipient, in conjunction with
the IDT, the flexibility to choose any or all of these service options in an
amount that does not exceed the eligible recipient’s ARA. Services funded within [the ARA include:]
[(1) behavioral support consultation;
(2) customized
community support;
(3) respite;
(4) non-medical
transportation;
(5) case
management; and
(6) nutritional
counseling.
B. Services from
the under 18 years of] 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 DOH family infant toddler program (FIT).
C. Service options
available outside of the ARA include:
(1) environmental
modifications;
(2) assistive
technology;
(3) remote
personal support technology;
(4) preliminary
risk screening and consultation; and
(5) socialization
and sexuality education.]
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; and
(11) nutritional counseling.
[8.314.5.14 NMAC -
Rp, 8.314.5.14 NMAC, 12/1/2018; A, 4/1/2022]
8.314.5.15 DDW Covered Waiver
Services [for identified population 18 years of age and older]:
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. 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. There
are seven proposed budget levels (PBL) which the IDT use for person centered
planning. They encompass descriptions
and characteristics of seven levels of typical support needs designed to meet
the needs of most individuals. Each PBL has
a corresponding suggested budget dollar amount based on the type of living care
arrangement, typical service options, intensity of staffing needs, and support
needs in each level. The case manager
guides the IDT in the person-centered planning process. The IDT makes a determination of which
proposed budget level the person falls based on history, current assessments,
and support needs, using both the PBL and suggested dollar amount as a tool or
guide in the person-centered planning process and in budget development. The OR approves services based on clinical
justification. Approvals may be over or
under the suggested amount. The OR does
not verify or approve the IDT’s determination of a PBL, nor does a PBL limit
the request for services or require that the budget be developed within a set
amount.
B. Exception
authorization process, formerly known as the H authorization process is the
process that allows individuals on the DDW, who have extenuating circumstances,
including extremely complex clinical needs to receive services beyond what is
authorized in their current ISP/budget level or to allow individual exceptions
to DDW service standards. Exception
authorization process includes:
(1) an
eligible recipient who is included in the class established in the matter of
Walter Stephen Jackson, et al vs. Fort Stanton Hospital and Training School et.
al, (757 F. Supp. 1243 DNM 1990) is to receive a permanent NM DDW exception
authorization approval. A Jackson class
member may receive service types and amounts consistent with those approved in
[his or her] their ISP.
(2) Exception
authorization packet includes: the completed individual supports needs review
form with all attachments indicated on the form as relevant to the nature/type
of exception authorization process request submitted.
C. When
determining what services the eligible recipient needs, the IDT should consider
the individual’s proposed budget level and service options with the
understanding that the focus must always be on the individual’s DDW support
needs that can be clinically justified.
Services available:
(1) Case
management services: Case management
services assist an eligible recipient to access MAD covered services. A case manager also links the eligible
recipient to needed medical, social, educational and other services, regardless
of funding source. 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 community supports to address the
eligible recipient's assessed needs in addition to paid supports. Case managers facilitate and assist in
assessment activities, as appropriate.
Case management services are person-centered and intended to advocate
for and support an eligible recipient in pursuing [his or her] their
desired life outcomes while gaining independence, and access to services and
supports. Case management is a set of
interrelated activities that are implemented in a collaborative manner
involving the active participation of the eligible recipient, [his or her]
their authorized representative, and the entire IDT. The case manager is an advocate for the
eligible recipient [he or she serves] they serve, is responsible
for developing the ISP and for ongoing monitoring of the provision of services
included in the ISP. Case management
services include but are not limited to activities such as:
(a) assessing
needs;
(b) [facilitating
eligibility determination for persons with developmental disabilities] assisting
in the submission process of the application for assistance and yearly
recertification to the local income support division (ISD) office;
(c) directing
the person-centered planning process;
(d) advocating
on behalf of the eligible recipient;
(e) [coordinating
service delivery under state plan;] coordinating waiver and state plan
service delivery and collaborating with managed care organization care
coordinators;
(f) assuring
services are delivered as described in the ISP;
(g) maintaining
a complete current central eligible recipient record (e.g. ISP, ISP budget,
level of care documentation, assessments);
(h) health
care coordination;
(i) assuring
cost containment by preventing the expense of DDW services from exceeding a
maximum cost established by DOH and by exploring other options to address
expressed needs.
(j) Case
managers must:
(i) evaluate
and monitor direct service through face-to-face visits with the eligible
recipient to ensure the health and welfare of the eligible recipient, and to
monitor the implementation of the ISP;
(ii) support
informed choice;
(iii) support
participant self-advocacy;
(iv) allow
participants to lead their own meetings, program and plan development;
(v) increase
an individual’s experiences with other paid, unpaid, publicly-funded and
community support options;
(vi) increase
self-determination;
(vii) demonstrate
that the approved budget is not replacing other natural or non- disability
specific resources available; and
(viii) document
efforts demonstrating choice of non-waiver and non-disability specific options
in the ISP, IDT meeting minutes or companion documents when an individual has
only DDW funded supports.
(2) Respite
services: Respite services are a
flexible family support service for an eligible recipient. The primary purpose of respite services is to
provide support to the eligible recipient and give the primary, unpaid
caregiver relief and time away from [his or her] their
duties. Respite services include
assistance with routine activities of daily living (e.g., bathing, toileting,
preparing or assisting with meal preparation and eating), enhancing self-help
skills and providing opportunities for play and other recreational activities;
community and social awareness; providing opportunities for community and
neighborhood integration and involvement; and providing opportunities for the
eligible recipient to make [his or her] their own choices with
regard to daily activities. Respite
services will be scheduled as determined by the primary caregiver. An eligible recipient receiving living
supports or customized in-home supports (when an eligible recipient is not
living with a family member), may not access respite services. Respite services may be provided in the
eligible recipient’s own home, in a provider's home, or in a community setting
of the eligible recipient family’s choice.
Respite services must be provided in accordance with 8.314.5.10 NMAC.
(3) Adult nursing services: Adult nursing services (ANS) are provided by
a licensed RN or LPN under the direct supervision of [a] the
RN to an eligible adult recipient. Adult
nursing services are intended to support the highest practicable level of
health, functioning and independence for an eligible recipient. [They include] This includes
the direct nursing services and activities related to the assessment,
planning, training and nursing oversight of unrelated direct support staff
when assisting with a variety of health related needs in specific
settings. Nursing services may be delivered in person
and via remote or telehealth services.
Nursing services include an array of supports including efforts to
support aspiration risk management (ARM).
Nursing services may be delivered in person and via remote or telehealth
services. Individuals and their health
care decision makers will be informed of telehealth service and technology as
part of the ISP process.
(a) ANS
is available to individuals ages 21 and over who reside in family living; those
who receive customized in home supports and those who do not receive any living
supports. It is available to any
eligible recipient who has health related needs that require at least one of
the following: nursing training, delegation or oversight of direct support staff
during participation in customized community supports (individual or small
group) or community integrated employment even if living supports or CCS-group
are also provided.
(b) ANS
is available to individuals ages 18-20 who reside in family living and who are
at aspiration risk and desire to have aspiration risk management services. It is also available to individuals who have
health related needs that require nursing training, delegation or the oversight
of non-related direct support staff during substitute care; customized
community supports (individual or small group); community integrated employment
or customized in home supports.
(c) There
are two categories of adult nursing services:
(i) assessment
and consultation services which includes a comprehensive health assessment
(including assessment for medication delivery needs and aspiration risk) and
consultation regarding available or mandatory services which requires only
budgeting; and
(ii) ongoing
services, which requires [prior authorization] clinical justification
and are tied to the eligible recipient's specific health needs revealed in the
comprehensive health assessment and prior authorization process.
(4) Therapy services: Therapy services are to be
delivered consistent with the participatory approach philosophy and two models
of therapy services (collaborative-consultative and direct treatment). These models support and emphasize increased
participation, independence and community inclusion in combination with health
and safety. DDW therapy services are
intended to improve, maintain or minimize the decline in functional ability and
skills. Therapy services are
designed to support achievement of ISP outcomes and prioritized areas of need
identified through therapeutic assessment.
PT, OT and SLP are skilled therapies that are recommended by an eligible
recipient's IDT members and a clinical assessment that demonstrates the need
for therapy services. Therapy
services may be delivered in an integrated setting, clinical setting, or
through telehealth as appropriate and will support the use of assistive or
remote personal support technology as needed.
Upon recommendation for therapy assessment by the IDT members [.
All] all three therapy disciplines:
PT, OT, and SLP will be available to all DDW recipients if [they and
their IDT members determine the therapy disciplines are necessary] the
therapy assessment indicates that services are needed. Individuals and their health care decision
makers will be informed of telehealth service and technology as part of the ISP
process. Therapy services for an
eligible adult recipient require a prior authorization except for [his or
her] their initial assessment.
A RLD licensed practitioner, as specified by applicable state laws and standards,
provides the skilled therapy services.
Therapy services for eligible adult recipients must comply with
8.314.5.10 NMAC. All medically necessary
therapy services for children under 21 years of age, are covered under the
state plan through the early periodic screening, diagnostic and treatment
(EPSDT) [benefit] and must comply with 8.320.2 NMAC. To the extent that any listed services are
covered under the state plan, the services under the waiver are additional
services not otherwise covered under the state plan, and consistent with DDW
objectives to support the recipient to remain in the community and
prevent institutionalization. The
exception is aspiration risk management supports for persons between age 18 and
21.
(a) Physical therapy (PT): PT is a skilled, RLD licensed therapy service
involving the diagnosis and management of movement dysfunction and the
enhancement of physical and functional abilities. Physical therapy addresses the restoration,
maintenance, and promotion of optimal physical function, wellness and quality
of life related to movement and health.
Physical therapy prevents the onset, symptoms and progression of
impairments, functional limitations, and disability that may result from
diseases, disorders, conditions or injuries.
PT supports access, mobility and independence in all environments. A RLD licensed physical therapy assistant
(PTA) may perform physical therapy procedures and related tasks pursuant to a
plan of care/therapy intervention plan written by the supervising physical
therapist. Therapy services for eligible
recipients must comply with 8.314.5.10 NMAC.
(b) Occupational therapy (OT): OT is a skilled, RLD licensed therapy service
involving the use of everyday life activities (occupations) for the purpose of
evaluation, treatment, and management of functional limitations. Therapy services for eligible recipients must
comply with 8.314.5.10 NMAC.
Occupational therapy addresses physical, cognitive, psychosocial,
sensory, and other aspects of performance in a variety of contexts to support
engagement [in everyday], performance and access to work and life
activities that affect health, well-being and quality of life. [COTAs] A RLD certified
occupational therapy assistant (COTA) may perform occupational therapy
procedures and related tasks pursuant to a therapy intervention plan written by
the supervising OT as allowed by RLD licensure.
[OT services typically include:
(i) evaluation
and customized treatment programs to improve the eligible recipient's ability
to engage in daily activities;
(ii) evaluation
and treatment for enhancement of an eligible recipient’s performance skills;
(iii) health and wellness
promotion to the eligible recipient;
(iv) environmental
access and assistive technology evaluation and treatment for use by the
eligible recipient; and
(v) training/consultation
to eligible recipient's family members and direct support personnel.]
(c) Speech-language pathology (SLP): SLP service, also known as speech therapy, is
a skilled therapy service, provided by a speech-language pathologist that
involves the non-medical application of principles, methods and procedures for
the diagnosis, counseling, and instruction related to the development of and
disorders of communication including speech, fluency, voice, verbal and written
language, auditory comprehension, cognition, swallowing dysfunction and
sensory-motor competencies. Therapy
services for eligible recipients must comply with 8.314.5.10 NMAC. Speech-language pathology services are also
used when an eligible recipient requires the use of assistive technology or
an augmentative communication device.
For example, SLP services are intended to improve, maintain or
minimize the loss of communication skills; treat a specific condition
clinically related to an intellectual developmental disability of the eligible
recipient; or improve or maintain the eligible recipient's ability to safely
eat food, drink liquids or manage oral secretions while minimizing the risk of
aspiration or other potential injuries or illness related to swallowing
disorders.
[ (i) improve
or maintain the eligible recipient's capacity for successful communication or
to lessen the effects of an eligible recipient's loss of communication skills;
or
(ii) treat
a specific condition clinically related to an intellectual developmental
disability of the eligible recipient; or
(iii) improve
or maintain the eligible recipient's ability to safely eat foods, drink liquids
or manage oral secretions while minimizing the risk of aspiration or other
potential injuries or illness related to swallowing disorders.]
(5) Living supports: Living supports are residential habilitation
services, available up to 24 hours a day, that are individually tailored to
assist an eligible recipient 18 year and older who is assessed to need daily
support or supervision with the acquisition, retention, or improvement of
skills related to living in the community to prevent institutionalization. Living supports include residential-type
instruction intended to increase and promote independence and to support an
eligible recipient to live as independently as possible in the community in a
setting of [his or her] their own choice. Living support services assist and encourage
an eligible recipient to grow and develop, to gain autonomy, self-direct and
pursue [his or her] their own interests and goals. Living supports includes support to
individuals to access: healthcare, dietary, nursing, therapy and behavior
supports through telehealth and in person appointments; generic and natural
supports, standard utilities including internet services, assistive and remote
technology, transportation, employment, and opportunities to establish or
maintain meaningful relationships throughout the community. Living supports providers are also required
to coordinate and collaborate with nursing, behavior support consultants,
dieticians, therapists and therapy assistants to implement plans including
aspiration risk management plans. Living
supports providers are also required to coordinate and collaborate with
behavior support consultants to implement positive behavior support plans.
Living support providers take positive steps to protect and promote the
dignity, privacy, legal rights, autonomy and individuality of each eligible
recipient who receives services.
Services promote inclusion in the community and an eligible recipient is
afforded the opportunity to be involved in the community and actively
participate using the same resources and doing the same activities as other
community members. [Living supports
will assist an eligible recipient to access generic and natural supports and
opportunities to establish or maintain meaningful relationships throughout the
community.] Living supports
providers are responsible for providing an appropriate level of services and
supports up to 24 hours per day, seven days per week. Room and board costs are reimbursed through
the eligible recipient's social security insurance (SSI) or other personal
accounts and cannot be paid through the DDW.
Living support services for eligible recipients must comply with
8.314.5.10 NMAC. Living supports
consists of family living, supported living, and intensive medical living as
follows.
(a) Family living (FL): Family living is intended for an eligible
recipient who is assessed to need residential habilitation to ensure health and
safety while providing the opportunity to live in a typical family
setting. Family living is a residential
habilitation service that is intended to increase and promote independence and
to provide the skills necessary to prepare an eligible recipient to live on [his
or her] their own in a non-residential setting. Family living services are designed to address
assessed needs and identified individual eligible recipient outcomes. Family living is direct support and
assistance that is provided to no more than two eligible recipients with
intellectual or developmental disabilities at a time furnished by a natural or
host family member, or companion who meets the requirements and is approved to
provide family living services in the eligible recipient's home or the home of
the family living direct support personnel.
The eligible recipient lives with the paid direct support
personnel. The FL provider agency is
responsible for providing nutritional services from a registered dietician or
licensed nutritionist. All FL providers
must be adult nursing services (ANS) providers and deliver budgeted nursing
services including nursing assessment and on call. The provider agency is responsible for up to
750 hours of substitute coverage for the primary direct support personnel to
receive sick leave and time off as needed.
An exception may be granted by DOH if three eligible recipients are in
the residence, but only two of the three are on the DDW and the arrangement is
approved by DOH based on the home study documenting the ability of the family
living [services] provider [agency] to serve more than two
eligible recipients in the residence; or there is documentation that identifies
the eligible recipients as siblings or there is documentation of the longevity
of a relationship (e.g., copies of birth certificates or social history
summary). Documentation shall include a
statement of justification from a social worker, psychologist, and any other
pertinent professionals working with the eligible recipients. Family living services cannot be provided in
conjunction with any other living supports service, respite, or additional
nutritional counseling accessed through the person’s budget. Family living provider must arrange
transportation for all medical appointments, household functions and
activities, and to-and-from day services and other meaningful community options. The family living services provider agency
shall complete all DOH requirements for approval of each direct support
personnel, including completion of an approved home study and training prior to
placement. After the initial home study,
an updated home study shall be completed annually. The home study must also be updated each time
there is a change in family composition or when the family moves to a new home or
other significant event. The content
and procedures used by the provider agency to conduct home studies shall be
approved by DOH and must include assessment of environmental safety.
(b) Supported living (SL): Supported living is intended for an eligible
recipient who is assessed to need residential-type habilitation support to
ensure health and safety. Supported
living is a living habilitation support service that is intended to increase
and promote independence and to provide the skills necessary to prepare an
eligible recipient to live on [his or her] their own in a
non-residential setting. Supported
living services are designed to address assessed needs and identified
individual eligible recipient outcomes.
The service is provided to two to four eligible recipients in a
community residence. Prior authorization
is required from DOH for an eligible recipient to receive this service when
living alone. The SL provider agency
is responsible for providing nutritional services from a registered dietician
or licensed nutritionist based on the person’s needs. All SL providers must provide needed nursing
services including on call based on the person’s needs. The SL provider must arrange transportation
to all medical appointments, household functions and activities, and
to-and-from day services and other meaningful community options. Supported living services cannot be provided
in conjunction with any other living supports service, respite, or additional
nutritional counseling assessed through the person’s budget.
(c) Intensive medical living [services]
supports: An intensive medical living supports agency
provides residential-type supports for an eligible recipient in a supported
living environment who requires daily direct skilled nursing, in conjunction
with community living supports that promote health and assist the eligible
recipient to acquire, retain or improve skills necessary to live in the
community and prevent institutionalization, consistent with [his or her]
their ISP. An eligible recipient
must meet criteria for intensive medical living supports according to DDW
service definitions and DDW standards for this service and [he or she
requires] they require nursing care, ongoing assessment, clinical
oversight and health management that must be provided directly by a MAD
recognized RN or LPN, see 8.314.5.10 NMAC.
(i) These
medical needs include: skilled nursing
interventions; delivery of treatment; monitoring for change of condition; and
adjustment of interventions and revision of services and plans based on
assessed clinical needs.
(ii) In
addition to providing support to an eligible recipient with chronic health
conditions, intensive medical living supports are available to an eligible
recipient who meets a high level of medical acuity and require short-term
transitional support due to recent illness or hospitalization. This service will afford the core living
support provider the time to update health status information and health care
plans, train staff on new or exacerbated conditions and assure that the home
environment is appropriate to meet the needs of the eligible recipient. Short-term stay in this model may also be
utilized by an eligible recipient who meets the criteria that is living in a
family setting when the family needs a substantial break from providing direct
service. Both types of short-term
placements require prior approval from DOH.
In order to accommodate referrals for short-term stays, each approved
intensive medical living supports provider must maintain at least one bed
available for such short-term placements.
If the short-term stay bed is occupied, additional requests for
short-term stay will be referred to other providers of this service.
(iii) The intensive medical living supports provider will be responsible for
providing the appropriate level of supports, 24 hours per day seven days a
week, including necessary levels of skilled nursing based on assessed need of
the eligible recipient. Daily nursing
visits are required; however, a RN or a LPN under a RN’s supervision is not
required to be present in the home during periods of time when skilled nursing
services are not required or when an eligible recipient is out in the
community. An on-call RN or LPN, under
the supervision of a RN must be available to staff during periods when a RN or
a LPN under a RN’s supervision is not present.
Intensive medical living supports require supervision by a RN, and must
comply with 8.314.5.10 NMAC.
(iv) Direct
support personnel will provide services that include training and assistance
with ADLs such as bathing, dressing, grooming, oral care, eating, transferring,
mobility and toileting. These services
also include training and assistance with instrumental activities of daily
living (IADL) including housework, meal preparation, medication assistance,
medication administration, shopping, and money management.
(v) The
intensive medical living supports provider will be responsible for providing
access to customized community support and employment as outlined in the
eligible recipient's ISP. This includes
any skilled nursing needed by the eligible recipient to participate in
customized community support and development and employment services. The intensive medical living provider must
arrange transportation for all medical appointments, household functions and
activities, and to-and-from day services and other meaningful community
options.
(vi) Intensive
medical living supports providers must comply with 8.314.5.10 NMAC.
(6) Customized community supports (CCS): [Customized community supports (CCS) consists]
CCS consists of individualized services and supports that enable an
eligible recipient to acquire, maintain, and improve opportunities for
independence, community integration and employment. Customized community supports services are
designed around the preferences and choices of each eligible recipient and
offer skill training and supports to include:
adaptive skill development; adult educational supports;
citizenship skills; communication; social skills, socially appropriate
behaviors; self-advocacy, informed choice; community integration and
relationship building. This service
provides the necessary support to develop social networks with community
organizations to increase the eligible recipient's opportunity to expand valued
social relationships and build connections within [local]
communities. This service helps to
promote self-determination, increases independence and enhances the eligible
recipient's ability to interact with and contribute to [his or her] their
community. Customized community supports are intended to
be provided in the community to the fullest extent possible. Customized community supports must not
duplicate services available through the New Mexico public education department
or the Individuals with Disabilities Education Act (IDEA).
(a) Based
on assessed needs, customized community supports services may include personal
support, nursing oversight, medication assistance or administration, and
integration of strategies in the therapy and healthcare plans into the eligible
recipient's daily activities.
(b) The
customized community supports provider may provide fiscal management for the
payment of adult education opportunities as determined necessary for the
eligible recipient.
(c) Customized
community supports services may be provided regularly or intermittently based
on the needs of the eligible recipient and are provided during the day,
evenings and weekends. Customized community supports are not limited to
specific hours or days of the week and should be provided in alignment with the
persons desired outcomes.
(d) Customized
community supports may be provided in a variety of settings to include the
community, classroom, remotely and at site-based locations,
depending on the ISP and the particular type of service chosen within CCS. Services provided in any location are
required to provide opportunities that lead to participation and [integration]
inclusion in the community or support the eligible recipient to increase
[his/her] their growth and development.
(e) Pre-vocational
and vocational services are not covered under customized community supports.
(f) Customized
community supports services must be provided in accordance with 8.314.5.10
NMAC.
(7) Community integrated employment (CIE): [Community integrated employment provides
supports that achieve employment in jobs of the eligible recipient's choice in
his or her community to increase his or her economic independence,
self-reliance, social connections and ability to grow within a career.] Community integrated employment is
intended to provide supports that result in jobs in the community which
increase economic independence, self-reliance, social connections, and the
ability to grow within a career. CIE
consists of intensive, ongoing services that support individuals to achieve
competitive integrated employment or business ownership who, because of their
disabilities, might otherwise not be able to succeed without supports to
perform in a competitive work setting or own a business. Community integrated employment results in
employment alongside non-disabled coworkers within the general workforce or in
business ownership. This service may
also include small group employment including mobile work crews or
enclaves. An eligible recipient is
supported to explore and seek opportunity for career advancement through growth
in wages, hours, experience or movement from group to individual
employment. Each of these activities is
reflected in individual career plans.
Community integrated employment services must not duplicate 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, New Mexico department of
workforce solutions (DWS), or the Workforce Innovation and Opportunities Act
(WIOA). Compensation shall comply
with state and federal laws including the Fair Labor Standards Act. DDW funds (e.g., the provider agency’s
reimbursement) may not be used to pay the eligible recipient for work. CIE services shall be provided based on
the interests of the person and desired outcomes listed in the ISP. Employment services are to be available 365
days a year, 24 hours a day.
Community integrated employment services must comply with 8.314.5.10
NMAC. Community integrated employment
consists of job development, self-employment, short term job coaching, job
maintenance, job aid, intensive [individual] community integrated
employment and group community integrated employment models.
[ (a) Self-employment: The community integrated employment provider
provides the necessary assistance to develop a business plan, conduct a market
analysis of the product or service and establish necessary infrastructure to
support a successful business.
Self-employment does not preclude employment in the other models. Self-employment may include but is not
limited to the following:
(i) completing
a market analysis of product/business viability;
(ii) creating
a business plan or accessing community resources to develop a business plan
including development of a business infrastructure to sustain the business over
time, including marketing plans;
(iii) referring
and coordinating with the division of vocational rehabilitation (DVR) for
possible funds for business start-up;
(iv) assisting
in obtaining required licenses, necessary tax identifications, incorporation
documents and completing any other business paperwork required by local and
state codes;
(v) supporting
the eligible recipient in developing and implementing a system of bookkeeping
and records management;
(vi) providing
effective job coaching and on-the-job training and skill development; and
(vii) arranging
transportation or public transportation during self-employment services.
(b) Individual community integrated employment: Individual community integrated employment is
job development and job coaching for an eligible recipient in integrated
community based settings. The amount and
type of individual support needed will be determined through a person-centered
assessment including on-the-job analysis.
Individual community integrated employment may include, but is not
limited to the following:
(i) promoting
career exploration based on interests within various careers through job
sampling, job trials or other assessments;
(ii) developing
and identifying community based job opportunities that
are in line with
the individual’s skills and interests;
(iii) developing
a résumé (written or visual) that identifies an individual’s relevant
vocational experiences;
(iv) negotiating
with employers for job customization, including facilitating job accommodations
and the use of assistive technology such as communication devices;
(v) supporting
the individual in gaining the skills and knowledge to advocate for themselves
in the workplace including the development of natural supports;
(vi) educating
the individual, the employer or other IDT members regarding rights and responsibilities
related to employment;
(vii) arranging
for or providing benefits counseling;
(viii) linking
the individual to employment resources in the community;
(ix) providing
effective job coaching and on-the-job training as needed to assist the eligible
recipient to maintain the job placement and enhance skill development; and
(x) arranging
transportation or public transportation during individual community integrated
employment services.
(c) Group community integrated employment: Group community integrated employment is when
more than one eligible recipient works in an integrated setting with staff
supports on site. Regular and daily
contact with non-disabled coworkers or the public occurs. Group community integrated employment may
include but is not limited to the following:
(i) participating
with the IDT to develop a plan to assist an eligible recipient who desires to
move from group employment to individual employment;
(ii) providing
effective job coaching and on-the-job training as needed to assist the eligible
recipient to maintain the job placement and enhance skill development;
(iii) negotiating
with employers for job customization, including facilitating job accommodations
and the use of assistive technology such as communication devices;
(iv) supporting
individuals in gaining the skills and knowledge to advocate for themselves in
the workplace including the development of natural supports; or
(v) educating
individuals, the employer or other IDT members regarding rights and
responsibilities related to employment.]
(a) Job development services through the
DDW can only be accessed when services are not otherwise available to the
beneficiary under either special education and related services as defined in
the Individuals with Disabilities Education Act (IDEA) or vocational
rehabilitation services available to the individual through a program funded
under section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730). Job development may include but is not
limited to, activities to assist an individual to plan for, accommodate,
explore and obtain CIE.
(b) Short term job coaching services
through the DDW can only be accessed when services are not otherwise available
to the beneficiary under either special education and related services as
defined in the Individuals with Disabilities Education Act (IDEA) or vocational
rehabilitation services available to the individual through a program funded
under section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730). Short term job coaching services may include
but are not limited to, activities to assist an individual to learn,
accommodate and perform work duties, and maintain employment.
(c) Job
maintenance is intended to be used as the long-term supports once all available
funding and services through vocational rehabilitation or the educational
systems has been utilized. Job
maintenance is provided on a one-to-one ratio.
Job maintenance services may include, but are not limited to, activities
to assist the individual to accommodate, maintain employment and career
advancement.
(d) Self-employment: Services through the DDW can only be accessed
when services are not otherwise available to the beneficiary under either
special education and related services as defined in the Individuals with
Disabilities Education Act (IDEA) or vocational rehabilitation services
available to the individual through a program funded under section 110 of the
Rehabilitation Act of 1973 (29 U.S.C. 730).
Self-employment services are intended to be used as the long-term
supports once all available funding and services through vocational
rehabilitation or the educational systems have been utilized. Self-employment does not preclude employment
in the other models. Self-employment may
include but is not limited to development of a business plan, conducting market
analysis, and establishing and supporting the infrastructure for a successful
business.
(e) Job
aid: One to one personal care services
in an individual, community integrated employment setting for people who
require assistance with activities of daily living (ADLs) during work hours to
maintain successful employment as job supports are reduced.
(f) Intensive
community integrated employment (ICIE):
Services for people who are working in an individual, community
integrated employment setting and require more than 40 hours of staff supports
per month to maintain their employment.
ICIE is the same scope of services as outlined in 8.314.5.10 NMAC.
(g) Group
community integrated employment: Group
community integrated employment is when more than one eligible recipient works
in an integrated setting with staff supports on site. Regular and daily contact with non-disabled
coworkers or the public occurs. Group
community integrated employment services may include but are not limited to
activities to assist the individual to accommodate, maintain and advance from
group to individual employment.
(8) Behavioral
support consultation services: [Behavioral support consultation services
guide the IDT to enhance the eligible recipient's quality of life by providing
positive behavioral supports for the development of functional and relational
skills. Behavioral support consultation
services also identify distracting, disruptive, or destructive behavior that
could compromise quality of life and provide specific prevention and
intervention strategies to manage and lessen the risks this behavior
presents. Behavioral support
consultation services do not include individual or group therapy, or any other
behavioral services that would typically be provided through the behavioral
health system.
(a) Behavioral
support consultation services are intended to augment functional skills and
positive behaviors that contribute to quality of life and reduce the impact of
interfering behaviors that compromise quality of life. This service is provided by an authorized
behavioral support consultant and includes an assessment and positive
behavioral support plan development, IDT training and technical assistance, and
monitoring of an eligible recipient's behavioral support services.]
The behavior
support consultation supports the person’s successful achievement of
vision-driven desired outcomes. Behavior
support consultation services identify behaviors that impact quality of life
and provide specific prevention and intervention strategies to manage and
lessen the risks these behaviors present.
This service is provided by an authorized behavior support consultant
and includes a positive behavior supports assessment and positive behavior
support plan development; interdisciplinary team (IDT) training and technical
assistance; and monitoring of an individual’s behavioral support services. Services may be provided in person for
training, evaluation or monitoring and remotely via telehealth as needed. Annual assessments require an in person
interview or observation except when conducted during declared state or national
emergencies or pandemics. Behavioral support
services include:
(a) Assessment of the person and their
environment, including barriers to independent functioning;
(b) Design
and testing of strategies to address concerns and build on strengths and skills
for independence;
(c) Writing
and training in the implementation of plans in a way that the person and direct
support personnel (DSP) can understand and implement them.
[(b)] (d) Behavioral support consultation services must
comply with 8.314.5.10 NMAC.
(9) Nutritional
counseling services: Nutritional counseling services
include the assessment, evaluation, collaboration, planning, teaching,
consultation and implementation and monitoring of a nutritional plan and
menu services that supports the eligible recipient to attain or maintain
the highest practicable level of health.
It may be provided by a registered/licensed dietician (RD/LD) or
licensed nutritionist (LN). This service
may be delivered in person or via telehealth.
The RD/LD/LN is an active member of the IDT and addresses overall
nutritional needs, diet, tube feeding, weight loss or gain, wounds and a
variety complex medical or behavioral conditions that have or may impact the
persons overall health. These [Nutritional]
nutritional counseling services are in addition to those nutritional or
dietary services allowed in the eligible recipient's medicaid state plan
benefit, or other funding source. This
service does not include oral-motor skill development services, such as those
services provided by a speech pathologist.
[Because nutritional counseling is included in the reimbursement rate
for living supports, nutritional] Nutritional counseling cannot be
billed as a separate service during the hours of living supports. Nutritional
counseling services must comply with 8.314.5.10 NMAC.
(10) Environmental modification services: Environmental modifications services include
the purchasing and installing of equipment or making physical adaptions to an
eligible recipient’s residence that are necessary to ensure the health, welfare
and safety of the eligible recipient or enhance [his or her] their
access to the home environment and increase [his or her] their
ability to act independently.
(a) Adaptations,
[instillations] installations and modifications include:
(i) heating
and cooling adaptations;
(ii) fire
safety adaptations;
(iii) turnaround
space adaptations;
(iv) specialized
accessibility, safety adaptations or additions;
(v) installation
of specialized electric and plumbing systems to accommodate medical equipment
and supplies;
(vi) installation
of trapeze and mobility tracks for home ceilings;
(vii) installation
of ramps [and grab-bars];
(viii) widening
of doorways or hallways;
(ix) modification
of bathroom facilities (roll-in showers, sink, bathtub and toilet modification,
water faucet controls, floor urinals and bidet adaptations and plumbing);
(x) purchase
or installation of air filtering devices;
(xi) purchase
or installation of lifts or elevators;
(xii) purchase
and installation of glass substitute for windows and doors;
(xiii) purchase
and installation of modified switches, outlets or environmental controls for
home devices; and
(xiv) purchase
and installation of alarm and alert systems or signaling devices.
(b) Excluded
are those adaptations or improvements to the home that are of general utility
and are not of direct medical or remedial benefit to the eligible
recipient. Adaptations that add to the
total square footage of the home are excluded from this benefit except when
necessary to complete an adaptation (e.g., in order to improve entrance/egress
to an eligible recipient’s residence or to configure a bathroom to accommodate
a wheelchair).
(c) Environmental
modification services must be provided in accordance with applicable federal,
state and local building codes.
(d) Environmental
modification services must comply with 8.314.5.10 NMAC.
(11) Crisis
supports: Crisis supports are services that provide
intensive supports by appropriately trained staff to an eligible recipient
experiencing a behavioral or medical crisis either within the eligible
recipient's present residence or in an alternate residential setting. Crisis support must comply with
8.314.5.10 NMAC.
(a) Crisis supports in the eligible
recipient's residence: These
services provide crisis response staff to assist in supporting and stabilizing
the eligible recipient while also training and mentoring staff or family
members, who normally support the eligible recipient, in order to remediate the
crisis and minimize or prevent recurrence.
(b) Crisis supports in an alternate
residential setting: These services
arrange an alternative residential setting and provide crisis response staff to
support the eligible recipient in that setting, to stabilize and prepare the
eligible recipient to return home or to move into another permanent
location. In addition, staff will
arrange to train and mentor staff or family members who will support the
eligible recipient long-term once the crisis has stabilized, in order to
minimize or prevent recurrence of the crisis.
(c) Crisis response staff will deliver
such support in a way that maintains the eligible recipient's normal routine to
the maximum extent possible. This
includes support during attendance at employment or customized community
supports services, which may be billed on the same dates and times of service
as crisis supports.
(d) This service requires prior written
approval and referral from the bureau of behavioral support (BBS). Crisis supports are designed to be a
short-term response (two to 90 calendar days).
(e) The timeline may exceed 90
calendar days under extraordinary circumstances, with approval from the BBS in
which case duration and intensity of the crisis intervention will be assessed
weekly by BBS staff.
(12) Non-medical transportation: Non-medical transportation services assists
the eligible recipient in accessing other waiver supports and non-waiver
activities identified in [his or her] their ISP. Non-medical transportation enables the
eligible recipient to gain physical access to non-medical community services
and resources promoting the eligible recipient opportunity and responsibility
in carrying out [his or her] their ISP activities. This service is to be considered only when
transportation is not available through the medicaid state plan or when other
arrangements cannot be made. Non-medical
transportation includes mileage reimbursement and funding to purchase a
pass for public transportation for the eligible recipient. Non-medical transportation provider services
must comply with 8.314.5.10 NMAC.
(13) Supplemental dental care: Supplemental
DDW dental care services are provided for an eligible recipient that requires
routine oral health care more frequently than the coverage provided under other
MAP benefit plans. Supplemental dental
care provides one oral examination and one cleaning once every ISP year to an
eligible recipient for the purpose of preserving or maintaining oral
health. The supplemental dental care
service must comply with 8.314.5.10 NMAC.
(14) Assistive technology [purchasing
agent service]: Assistive
technology (AT) purchasing agent service is intended to support the
access of low tech devices that increase the eligible recipient's physical
and communicative participation in functional activities at home and in the
community. Items purchased through the
assistive technology service assist the eligible recipient to meet outcomes
outlined in [his or her] their ISP, increase functional
participation in employment, community activities, activities of daily living,
personal interactions, or leisure activities, or increase the eligible
recipient's safety during participation of the functional or leisure
activity.
(a) The assistive
technology [services] service allows an eligible recipient to
purchase or obtain needed items to develop low-tech augmentative communication, environmental access,
mobility systems and other functional assistive technology, not covered through
the eligible recipient's medicaid state plan benefits.
(b) [Assistive
technology purchasing agent providers act as a fiscal agent to either directly
purchase, or reimburse team members who purchase devices or materials which
have been prior authorized by DOH on behalf of the eligible recipient.]
Assistive technology may be accessed
through an approved waiver provider acting as a purchasing agent for technology
vendors whose products meet definition and needs or directly through an
approved technology provider who is the direct vendor of the service and
approved DDW provider.
(c) Assistive technology [purchasing
agent services] must comply with 8.314.5.10 NMAC.
(15) Independent living transition services: Independent living transition services are
one-time set-up expenses for an eligible recipient who transitions from a 24
hour living supports setting into a home or apartment of [his or her] their
own with intermittent support that allows [him or her] them to
live more independently in the community.
The service covers expenses associated with security deposits that are
required to obtain a lease on an apartment or home, set-up fees or deposits for
utilities (telephone, internet, electricity, heating, etc.), and
furnishings to establish safe and healthy living arrangements, such as a bed,
chair, dining table and chairs, eating utensils and food preparation items, and
a [telephone] cell phone.
The service also covers services necessary for the eligible recipient's
health and safety such as initial or one-time fees associated with the cost of
paying for pest control, allergen control or cleaning services prior to
occupancy. Independent living transition
services must comply with 8.314.5.10 NMAC.
(16) [Personal support technology/on-site
response service] Remote personal support technology: [Personal support technology/on-site
response service is an electronic device or monitoring system that supports the
eligible recipient to be independent in the community or in his or her place of
residence with limited assistance or supervision of paid staff. This service provides 24-hour response
capability or prompting through the use of electronic notification and
monitoring technologies to ensure the health and safety of the eligible
recipient in services. Personal support
technology/on-site response service is available to the eligible recipient who
has a demonstrated need for timely response due to health or safety
concerns. Personal support
technology/on-site response service includes the installation of the rented
electronic device, monthly maintenance fee for the electronic device, and
hourly response funding for staff that support the eligible recipient when the
device is activated. Personal support
technology/on-site response services must comply with 8.314.5.10 NMAC.] Remote
personal support technology is an electronic device or monitoring system that
supports individuals to be independent in the community or in their place of
residence with limited assistance or supervision of paid staff. This service provides up to 24-hour alert,
monitoring or remote personal emergency response capability, remote prompting
or in-home reminders, or environmental controls for independence through the
use of technologies. The service is
intended to promote independence and quality of life, to offer opportunity to
live safely and as independently as possible in one’s home, and to ensure the
health and safety of the individual in services. Remote personal support technology is
available to individuals who may want to live independently in their own homes,
may have a demonstrated need for timely response due to health or safety
concerns, or may be afforded increased independence from staff supervision in
residential services. The use of
technology should ease life activities for individuals and their families. Remote personal support technology includes
development of individualized response plans with the installation of the
electronic device or sensors, monthly maintenance, rental or subscription
fees. This service is not intended to
provide for paid, in-person on-site response.
On-site response must be planned through response plans that are
developed using natural or other paid supports for on-site response. Remote personal support technology may be
accessed through an approved waiver provider acting as a purchasing agent for
technology vendors whose products meet definition and needs or directly through
an approved technology provider who is the direct vendor of the service and
approved DDW provider.
(17) Preliminary risk screening and consultation
related to inappropriate sexual behavior (PRSC): [PRSC identifies, screens, and
provides periodic technical assistance and crisis intervention when needed to
the IDTs supporting the eligible recipient with risk factors for sexually
inappropriate or offending behavior, as defined in the DDW definitions and DDW
standards. This service is part of a
continuum of behavioral support services (including behavioral support
consultation, and socialization and sexuality services) that promote community
safety and reduce the impact of interfering behaviors that compromise quality
of life.] PRSC is designed to assess continued risk of sexually
inappropriate or offending behavior in persons who exhibit or have a history of
exhibiting risk factors for these types of behaviors. This service is part of a variety of behavior
support services (including BSC and socialization & sexuality education)
that promotes community safety and reduces the impact of interfering behaviors
that compromise the person’s quality of life.
PRSC is provided by a licensed mental health professional who has been
trained and approved as a risk evaluator by the BBS.
(a) The
key functions of PRSC are to:
(i) provide
a structured screening of the eligible recipient’s behaviors that may be
sexually inappropriate;
(ii) develop
and document recommendations of the eligible recipient in the form of a report
or consultation notes;
(iii) develop
and periodically review risk management plans for the eligible recipient, when
recommended; and
(iv) provide
consultation regarding the management and reduction of the eligible recipient’s
sexually inappropriate behavioral incidents that may pose a health and safety
risk to the eligible recipient or others.
(b) Preliminary
risk screening and consultation related to inappropriate sexual behavioral
services must comply with 8.314.5.10 NMAC.
(18) Socialization and sexuality education
service: [Socialization and
sexuality education service is
carried out through a series of classes intended to provide a proactive
educational program about the values and critical thinking skills needed to
form and maintain meaningful relationships, and about healthy sexuality and
sexual expression. Social skills
learning objectives include positive self-image, communication skills, doing
things independently and with others, and using paid and natural supports. Sexuality learning objectives include
reproductive anatomy, conception and fetal development, safe sex and health
awareness. Positive outcomes for the
eligible recipient include safety from negative consequences of being sexual,
assertiveness about setting boundaries and reporting violations, expressing physical
affection in a manner that is appropriate, and making informed choices about
the relationships in the eligible recipient’s life. Independent living skills are enhanced and
improved work outcomes result from better understanding of interpersonal boundaries,
and improved communication, critical thinking and self-reliance skills.] Socialization
and sexuality education in the form of the friends & relationships
course (FRC) is a comprehensive lifelong adult education program that teaches
students knowledge and skills to increase social networks with healthy,
meaningful relationships and to increase personal safety including decreasing
interpersonal and intimate violence in relationships, sexual victimization,
exploitation and abuse. This enhances
their ability to develop close friendships and romantic relationships. The FRC involves the person’s network of
support (natural supports, paid supports, teachers, nurses, family members,
guardians, friends, advocates, or other professionals) teaching them to support
the social and sexual lives of persons with I/DD, through participation in
classes, and by using trained and paid self-advocates as role models and peer
mentors in classes. Socialization
and sexuality education services must comply with 8.314.5.10 NMAC.
(19) Customized
in-home supports: Customized in-home support services is
not a residential habilitation service and is intended for an eligible
recipient that does not require the level of support provided under living
supports services. Customized in-home
supports provide an eligible recipient the opportunity to design and manage the
supports needed to live in [his or her] their own home or family
home. Customized in-home supports
include a combination of instruction and personal support activities provided
intermittently to assist the eligible recipient with ADLs, meal preparation,
household services, and money management.
The services and supports are individually designed to instruct or
enhance home living skills, community skills and to address health and safety
of the eligible recipient, as needed.
This service provides assistance with the acquisition, improvement or
retention of skills that provides the necessary support to achieve personal outcomes
that enhance the eligible recipient's ability to live independently in the
community. Services are delivered by
a direct support professional in the individuals own home or family home in the
community. Services may be provided as
part of on-site response plan with use of remote personal support
technology. This service is intended to
provide intermittent support and cannot be provided 24 hours a day/seven days a
week. Customized in-home support
services must comply with 8.314.5.10 NMAC.
[8.314.5.15 NMAC -
Rp, 8.314.5.15 NMAC, 12/1/2018; A, 4/1/2022]
8.314.5.16 NON-Covered Services: 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 [his and her] their DDW services. If the eligible recipient is an enrolled
member of a HSD managed care organization (MCO), [he or she] they
may access, as medically necessary, the benefits listed in 8.308.9 NMAC.
[8.314.5.16 NMAC -
Rp, 8.314.5.16 NMAC, 12/1/2018; A, 4/1/2022]
8.314.5.17 Individualized
Service plan (isp):
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.
B. The
IDT must review the eligible recipient’s person-centered plan every 12 months
or more often if indicated.
C. The
IDT is responsible for compiling clinical documentation to justify the requested
services and budget to the OR for adult recipients excluding class members of
Walter Stephen Jackson, et al vs. Fort Stanton Hospital and Training School et.
al, (757 F. Supp. 1243 DNM 1990).
D. The
person-centered service plan must consist of the following:
(1) identifies risks and includes a plan to reduce any risks;
(2) incorporates other health concerns (e.g. mental health, chemical health, chronic medical conditions, etc.);
(3) is written in plain language;
(4) records the alternative HCBS that were considered by the person;
(5) includes natural supports and services;
(6) includes strategies for solving conflict or disagreement within the process, including any conflict of interest guidelines for planning participants;
(7) identifies who is responsible for monitoring implementation of the plan;
(8) includes the person’s strengths;
(9) describes goals or skills that are related to the person’s preferences;
(10) includes a global statement about the person’s self-determined goals and aspirations;
(11) details what is important to the person; and
(12) includes a method for the individual to request updates to the plan, as needed.
E. Upon completion
of the ISP by the IDT, the case manager shall develop a budget to be evaluated
in accordance with the outside reviewer (OR) process; see Subsection D of
8.314.5.18 NMAC.
F. Upon completion
of the ISP by the IDT, the case manager shall develop a budget to be evaluated
in accordance with the medicaid third party assessor (TPA) review process for [child
recipients and] class members of Walter Stephen Jackson, et al vs. Fort
Stanton Hospital and Training School et. al, (757 F. Supp. 1243 DNM 1990).
G. All services
must be provided as specified in the ISP.
H. The case manager must conduct a pre ISP meeting annually
with the recipient to evaluate and plan for upcoming ISP term. The CM is required to meet with the DD Waiver
participant and guardian prior to the ISP meeting. The CM reviews current assessment information,
prepares for the meeting, creates a plan with the person to facilitate or
co-facilitate the meeting if desired, discusses the budget, reviews the current
secondary freedom of choice forms, and facilitates greater informed
participation in ISP development by the person.
[8.314.5.17 NMAC -
Rp, 8.314.5.17 NMAC, 12/1/2018; A, 4/1/2022]
8.314.5.18 Prior
AUTHORIZATION and Utilization Review: All MAD services, including
services covered under the DDW, are subject to utilization review for medical
necessity and program compliance.
Reviews may be performed before services are furnished, after services
are furnished and before payment is made, or after payment is made; see 8.310.2
NMAC. Once enrolled, providers receive
instructions and documentation forms necessary for prior authorization and
claims processing.
A. MAD prior authorization: To
be eligible for DDW services, a MAD eligible recipient must require the level
of care (LOC) of services provided in an ICF-IID. LOC determinations are made by MAD or its
designee. The eligible recipient’s
person centered ISP must specify the type, amount and duration of services and
meet clinical criteria. Certain
procedures and services specified in the ISP may require prior authorization
from MAD or its designee. Services for
which prior authorization was obtained remain subject to utilization review at
any point in the payment process.
B. DOH prior authorization: Certain services are subject to utilization
review by DOH.
C. Eligibility determination: Prior authorization of services
does not guarantee that individuals are eligible for MAD services. Providers must verify that individuals are
eligible for MAD services, including DDW services or other health insurance
prior to the time services are furnished.
An eligible recipient may not be institutionalized, hospitalized, or
receive personal care option (PCO) services or other HCBS waiver services at
the time DDW services are provided, except for certain case management services
that are required to coordinate discharge plans or transition of services to
DDW services.
D. Outside review process: All
services for [adult] DDW recipients excluding class members of
Walter Stephen Jackson, et al vs. Fort Stanton Hospital and Training School et.
al, (757 F. Supp. 1243 DNM 1990) will be reviewed by an OR contracted by
DOH. The OR will adhere to deadlines set
forth in its contract with the DOH. The
OR will apply the DDW clinical criteria to make a clinical determination on
whether the requested services and service amounts are needed, and will
recommend whether the requested annual budget and ISP should be approved. If the OR approves in whole or part the
requested ISP and budget, the OR will send the approved portion of the budget
to the medicaid TPA for entry into the medicaid management information system
and issue a prior authorization to the case manager. If there is a denial in part or whole, the OR
decision must be in writing, identify a list of all documents and input
considered by the OR team during its review, and state the reasons for any
denial of requested services. The
eligible recipient, case manager, and guardian (if applicable) will be provided
with this written determination and notice of an opportunity to request a fair
hearing as well as an agency review conference.
(1) The
eligible recipient, case manager, and guardian (if applicable) may submit to
the OR additional information relating to support needs.
(2) The
decision of the OR approving services requested by the DDW participant is
binding on the State. However, the state
may agree to overturn a decision to deny services requested by the DDW
participant at a requested agency conference.
E. Reconsideration: Providers who disagree with the denial of a
prior authorization request or other review decisions may request a
reconsideration. See 8.350.2 NMAC,
Reconsideration of Utilization Review Decisions.
[8.314.5.18 NMAC -
Rp, 8.314.5.18 NMAC, 12/1/2018; A, 4/1/2022]
8.314.5.20 RIGHT TO A HSD ADMINISTRATIVE HEARING: An
eligible recipient may request a HSD administrative hearing to appeal a
decision of MAD or its third party assessor contractor, or the OR, that is an
adverse action against the recipient.
Prior to the fair hearing an eligible recipient may be offered an agency
review conference. An agency review
conference (AC) means an optional conference offered by the DOH to provide an
opportunity to informally resolve a dispute over the denial, suspension,
reduction, termination or modification of DDW benefits or services. An AC will be attended by the recipient and
their authorized representative if applicable, representatives of the outside
review, DOH and any other necessary parties.
The recipient may also bring whomever [he or she wishes] they
wish to assist during the AC. The AC
is optional and shall in no way delay or replace the fair hearing process or
affect the deadline for a fair hearing request.
A. An authorized
representative means any individual designated by the eligible recipient or [his
or her] their guardian, if applicable, to represent the recipient
and act on their behalf. The authorized
representative must provide formal documentation authorizing [him or her] them to access the identified case information for this specific purpose. An
authorized representative may be, but need not be, the
recipient’s guardian or attorney.
B. The DOH will issue written notification describing
the outcome of the AC and any agreements within seven business days of the AC to the recipient, recipient’s guardian if applicable, and case manager.
C. Unless the fair hearing request is withdrawn by the recipient or
recipient’s guardian or lawyer, any requested fair hearing will proceed. At the fair hearing the claimant may raise
any relevant issue and present any relevant information that [he or she
chooses] they choose. See
8.352.2 NMAC for a description of a claimant’s HSD administrative hearing
rights and responsibilities.
D. In addition to
the requirements set forth in 8.352.2 NMAC, HSD and DOH shall take such actions
as are necessary to assure the presence at the hearing of all necessary
witnesses within DOH’s control, including, when relevant to a denial of
services or when requested by the claimant, a representative of the OR with
knowledge of the claimant’s case and the reason(s) for the denial, in whole or
in part, of any requested services.
E. Denials of
services through the exception authorization process or other actions during
this process adverse to the participant can also be appealed through a fair
hearing.
F. All HSD
administrative hearings are conducted in accordance with state and federal law.
G. No ex parte
communications with an HSD administrative law judge are permitted by any DDW
participant or counsel regarding any pending case. The MAD director shall not have ex parte
communications regarding any pending cases with any DDW participant or counsel
involved in that case. The MAD
director’s decision shall be limited to an on the record review.
[8.314.5.20 NMAC -
Rp, 8.314.5.20 NMAC, 12/1/2018; A, 4/1/2022]