TITLE 8 SOCIAL SERVICES
CHAPTER
326 CASE MANAGEMENT SERVICES
PART 10 BRAIN
INJURY SERVICES FUND PROGRAM
8.326.10.1 ISSUING
AGENCY: New Mexico Health Care
Authority.
[8.326.10.1 NMAC - Rp, 8.326.10.1 NMAC, 4/1/2021; A, 7/1/2024]
8.326.10.2 SCOPE: This rule applies to the general public.
[8.326.10.2 NMAC - Rp, 8.326.10.2 NMAC, 4/1/2021]
8.326.10.3 STATUTORY
AUTHORITY: Subsection E of Section
9-23-6 NMSA 1978. Section
9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single,
unified department to administer laws and exercise functions relating to health
care facility licensure and health care purchasing and regulation.
[8.326.10.3 NMAC - Rp, 8.326.10.3 NMAC, 4/1/2021; A,
7/1/2024]
8.326.10.4 DURATION: Permanent.
[8.326.10.4 NMAC - Rp, 8.326.10.4 NMAC, 4/1/2021]
8.326.10.5 EFFECTIVE
DATE: April 1, 2021, unless a
later date is cited at the end of a section.
[8.326.10.5 NMAC - Rp, 8.326.10.5 NMAC, 4/1/2021]
8.326.10.6 OBJECTIVE: The objective of
this rule is to establish policies and procedures and define standards of the
New Mexico human services department (HSD) brain injury services fund program. The brain injury services fund program
provides timely short term in-state non-medicaid services for persons with
qualifying brain injuries that are of traumatic or other acquired origin in
order to promote independence and to assist the individual in resolving a
brain-injury related crisis need and access available payer sources and
community resources, when there is no other funding available.
[8.326.10.6 NMAC - Rp, 8.326.10.6 NMAC, 4/1/2021]
8.326.10.7 DEFINITIONS:
A. "Acquired brain injury" (ABI)
means a brain injury that is the result of trauma arising from an insult to
the brain from an outside physical force via open or closed head injury; shaken
baby syndrome; anoxia; near-drowning; electrical shock; brain infection; brain
tumors; cerebrovascular lesions or insults, including stroke and aneurysm; or
unintended toxic or chemical exposure.
The definition excludes conditions that are congenital, degenerative,
induced by birth trauma, or resulting from abuse of alcohol or other
substances. The injury may be focal or
diffuse, causing temporary or permanent impairments in cognitive, psychosocial
or physical functioning affecting one or more areas of the brain and result in
partial or total functional disability.
Brain injury related impairments may affect one or more areas of
functioning such as: cognition; language; memory; attention; reasoning;
abstract thinking; judgment; problem-solving; information processing; sensory,
perceptual, and motor abilities; physical functioning; sleep; psychosocial and
behavioral functioning; and, or speech.
B. "Activities of daily
living" (ADL) means the basic tasks that are necessary for independent
functioning to care for one's personal needs and may include bathing and
showering, personal hygiene and grooming, dressing, toileting, transferring or
moving the physical body in space while performing activities, and
self-feeding. Instrumental activities of
daily living (IADLs) are not necessary for fundamental functioning but do allow
an individual to live independently in their home or community; these include
cleaning and maintaining the home, doing laundry, managing personal finances,
preparing meals, shopping for groceries, taking prescribed medications, and
using the telephone or other communication devices.
C. “Brain injury”. See
definition for acquired brain injury and traumatic brain injury.
D. “Brain
injury services fund (BISF) program” means a non-medicaid program
administered by HSD through programmatic oversight and contractual management
of agencies, providing short-term crisis interim home and community-based
services for eligible individuals living with brain injury, who have a defined
crisis related to living with brain injury and no responsible funding source to
pay for needed services or goods. Direct
participant care services are provided through service coordination or BISF
home and community-based services.
E. "Crisis" means
an emergency or unstable situation that has reached a critical phase with a
distinct possibility of adverse outcome and poses a serious potential
danger. As related to a brain injury, a
crisis may include homeless status, unemployment, substantial loss of income,
lack of health insurance or means to pay for brain-injury related healthcare,
separation from support systems, abandonment or other endangering
circumstances. For the purposes of the
BISF, the absence of service coordination, long-term care, long-term case
management or need for long-term case management does not constitute a crisis.
F. "Crisis interim period" means a short-term period of
six months upon which an enrolled participant can be reassessed to extend
approved services for another six month period depending upon available funding
and limited to no more than one consecutive year, if the crisis has not
resolved and goals for independent living have not reached completion, or until
another funding source has been obtained.
Time limitations on services apply to both service coordination and to
BISF HCBS.
G. "Education" means
providing individuals living with brain injury training and understanding of brain
injury, acquiring life skills or fulfilling activities of daily living, which
can be applied day to day, to assist in the attainment of an independent
lifestyle.
H. "Fiscal intermediary agency" means an agency that arranges for BISF
home and community-based services and goods and processes payment or
reimbursement for services and goods for eligible participants of the New
Mexico human services department brain injury services fund program.
I. “Formulary” or “BISF formulary” means the list of medications
approved by the BISF program for treatment of specific categories of brain
injury symptoms and related conditions.
Coverage is in the form of copayments for participants who have no other
responsible payer sources. Approved
generic and brand name medications are categorized by class or function. BISF service coordinators are authorized to
review prescribed participant medications against the formulary in the event
that other responsible payer sources to cover the medication do not exist prior
to referral for BISF HCBS.
J. "Grievance" means a complaint or disagreement
with regard to how or whether a service provided through the program is or can
be provided.
K. “Home
and community-based services” (HCBS)
are defined as services to promote independent living that are provided in a
person’s home
or community,
i.e., those not provided under institutional care.
BISF HCBS are those that may be
required when there is an imminent risk to a participant’s health and safety;
there has been a sudden change in the medical, psychological or physical
condition of a participant; when there is acceleration in the amount of
services needed; when needs have suddenly changed; or when another payer source
will not pay for the unique brain injury
services assessed as a need.
L. “Human services department (HSD)” is the New Mexico state government
agency that administers services to New Mexico’s more vulnerable populations to
improve health outcomes through state and federal funding. The brain injury services fund is
administered through the medical assistance division and receives only state
funding.
M. “ICD code” means an international classification
of diseases diagnosis, which includes codes for traumatic and other acquired
brain injuries and has been documented in writing by a duly licensed medical
professional or psychologist for the purpose of assisting an individual with
brain injury to qualify for the BISF program.
Current ICD codes may be accepted from medical doctors (MDs),
osteopathic doctors (DOs), certified nurse practitioners (CNPs), physician
assistants (PAs), and Ph.D. psychologists.
N. "Imminent" means impending and threatening, referring to a crisis that is
bound to happen with a clear and present danger to the health and safety of a
person who has sustained a brain injury and who has exhausted all available
resources.
O. "Independence" means
the ability to live in a home and community setting and perform activities of
daily living with little or no assistance from others while having access to
available community resources.
P. "Individual" means a
person living with brain injury and may be an applicant or a program
participant.
Q. “Independent living plan” (ILP)
means a written person-centered plan that outlines definite goals for resolving
a participant’s identified crisis which is designed to assist the participant
toward greater independence; lists measurable objectives in the form of action
steps and strategies that are targeted to comprehensively address and resolve
each identified crisis; and specifies a plan for discharge. The ILP identifies all services and supports
as well as payer sources that are assisting the participant toward greater
independence, specifying those that pertain directly to service coordination and
BISF HCBS. It must also list ancillary
services and supports, not paid for by the BISF program, noting related payer
sources, as well as services refused but needed to resolve or address
identified crises.
R. "Interim" means a time period defined by the BISF program in which temporary
services are provided. The interim
period for the BISF program is six months.
S. "Legal resident of New Mexico" means a person residing in New
Mexico at the time of application.
T. "Life skills coach"
means a person, who may be defined as a “life coach”, is certified through an
accredited organization, and provides targeted customized training to an
individual with brain injury to assist in relearning and completing activities
of daily living while addressing related cognitive, behavioral or social
impairments that are preventing the return to independent functioning.
U. “Participant” means a person living with brain injury, who has qualified for,
been approved for, and is actively receiving BISF program services, while
working toward greater independence and resolution of crisis needs.
V. "Payer of last resort"
refers to the BISF Program as a source of funding available to pay for BISF
HCBS only after all payer sources with responsibility to pay have been denied
or exhausted including private insurance, medicaid, medicare, Indian health services,
veterans administration, adult protective services and other state or federal
programs, or community programs in which the participant participates
voluntarily.
W. "Residency" means the status of a person who is a legal resident of New
Mexico and is able to produce documentation of a physical address within New
Mexico at which the person resides within a home and community setting. It does not include residence in an
institution wherein the individual is unable to function independently.
X. "Risk" means a possible loss or injury, a hazard increasing the
probability or chance that loss or injury will occur.
Y. "Self-determination"
means the right of individuals to make decisions that direct the path their
life follows with regard to medical, financial and all other matters, including
the right to refuse measures needed to improve their outcome.
Z. "Service coordination" means the goal-oriented initiation, organization and management
of a BISF participant’s services, including determination of eligibility,
initial and interim assessments, development and monitoring of the
participant’s independent living plan (ILP), referrals for BISF program and
community resources, assistance with benefits applications for other payer
sources, and problem-solving to assist in the resolution of the crisis that
motivated entry to the BISF program, while moving the participant toward
greater independence in daily living.
Service coordination may continue during resolution of an identified
crisis need. Service coordination is not
defined as case management, and the need for long-term case management does not
constitute a qualifying crisis for remaining on the BISF.
AA. "Short-term" means an
intervention period with beginning and end points within which BISF funding for
service coordination or BISF HCBS may be used to prevent or alleviate a crisis
situation until circumstances stabilize or other funding is obtained.
BB. "Traumatic brain injury
(TBI)" means an insult to the brain from an outside physical force
that may or may not have produced a diminished or altered state of
consciousness causing temporary or permanent impairments in one or more areas
of the brain and resulting in partial or total functional disability and or
psychosocial disorientation. The term
applies to open or closed head injuries resulting in an impairment of cognitive,
psychosocial or physical functions. Brain
injury related impairments may occur in one or more areas such as: cognition;
language; memory; attention; reasoning; abstract thinking; judgment;
problem-solving; information processing, sensory, perceptual, and motor
abilities; physical functioning; sleep; psychosocial and behavioral
functioning; and speech.
[8.326.10.7 NMAC - Rp, 8.326.10.7 NMAC, 4/1/2021]
8.326.10.8 MISSION
STATEMENT: To
transform lives. Working with our
partners, we design and deliver innovative, high quality health and human
services that improve the security and promote independence for New Mexicans in
their communities.
[8.326.10.8 NMAC - Rp, 8.326.10.8 NMAC, 4/1/2021]
8.326.10.9 BISF ELIGIBILITY REQUIREMENTS: Enrollment into the BISF, as a non-entitlement
program, is on a voluntary basis and occurs in up to six month increments. To be eligible for the BISF program, an
applicant with a crisis need must meet the following requirements:
A. Diagnosis: Individuals are eligible for BISF services if
they have a qualifying diagnosis of brain injury of ABI or TBI which has been
documented in writing by a duly licensed medical professional or psychologist. A qualifying diagnosis of brain injury is
confirmed by the licensed health practitioner’s assignment of the current
international classification of diseases (ICD) code.
B. Residency: Eligible individuals must be legal residents
of the state of New Mexico. Eligible
participants must be able to produce documentation of the physical location of
their New Mexico residence. Those
residing in an institution or are in the process of transitioning to an
institutional setting are not eligible for services through the BISF
program. Those participants who have a
confirmed discharge date from an institutional setting and are transitioning
into the community are eligible for BISF services for a 30-day period prior to
the planned discharge date to assist with setting up needed supports and
services. For homeless participants with
brain injury, the physical address constitutes the agreed-upon location at which
the participant routinely meets with the BISF service coordinator and at least
one other community case manager, if available.
C. Service Coordination Duplication: Those participants served by other service
coordination programs, care coordination or case management systems are not
eligible to receive service coordination through the BISF program, unless
transitioning between programs and with HSD approval. Such programs might include comparable
services offered through any of the following:
(1) medicaid
managed care organization (MCO), including community benefit;
(2) medicaid
home and community-based services waivers;
(3) early
and periodic screening, diagnosis and treatment;
(4) family
infant toddler;
(5) program
of all-inclusive care for the elderly (PACE);
(6) health
management organizations (HMOs); and
(7) other
private insurances.
D. Determination of eligibility: The service coordination contractor is
responsible for determining eligibility for the BISF program and maintaining
documentation of eligibility status.
Proof of eligibility status including current qualifying ICD codes must
be provided to the HSD or its designee upon request.
E. Re-enrollment
into the BISF for reactivation of services: Former program participants, who
disenrolled from the program due to resolution of their crisis needs, may seek
to re-enroll in the BISF, in the event that a new crisis arises with which they
require the program’s assistance.
Re-enrollment allows for the reactivation of service coordination and
BISF HCBS without providing a new ICD code, in the event that a qualifying code
continues to be on file.
F. Continuation of BISF services
beyond one consecutive service year. Program participants who
have not experienced a resolution of their crisis need(s) within two
consecutive six month interims of service may be eligible to continue service
coordination or BISF HCBS for additional interim periods for up to another
service year as funding allows. The
petition for continuation of services requires written justification by the
service coordination agency, following the standards established by HSD. In no case will continuation of services be
permitted without written approval by HSD to extend services beyond one service
year.
G. Disenrollment from the BISF: Disenrollment from the BISF may be voluntary
or involuntary.
(1) Voluntary disenrollment: Participants may voluntarily disenroll from
the program without cause at any time.
In addition, participants are no longer eligible to receive service
coordination or BISF HCBS services when any of the following apply:
(a) other responsible payer sources have
been identified and have begun coverage;
(b) the crisis or crises that caused the
participant to seek enrollment have been resolved; or
(c) upon a permanent move out of the state of New Mexico. The service coordination agency will give
such participants reasonable advance notice of pending disenrollment and
continue furnishing any needed services until the terms for disenrollment have
been met and the disenrollment is complete.
Upon disenrollment, all services will be inactivated.
(2) Involuntary
disenrollment: Participants of the
BISF may be disenrolled involuntarily if any of the following circumstances
apply, subsequent to reasonable efforts of the service coordination agency to
provide technical assistance to improve the participant’s understanding of
program expectations and as noted below:
(a) The participant refuses to act in
accordance with the requirements of their independent living plan (ILP) or
otherwise participate in the resolution of their crisis needs, exercising the
capabilities that remain within their power or that of their authorized
representative. This describes
participants who repeatedly fail to follow through with keeping appointments
with the service coordinator or access needed and recommended services;
(b) The participant refuses to act in
accordance with the program’s participant rights and responsibilities, as
explained by the service coordination agency and signed by the participant upon
program intake;
(c) The participant’s physical,
behavioral, psychosocial or service needs exceed that which can be reasonably
provided by the program or be met with available funding;
(d) The participant engages in disruptive
or threatening behavior. This describes
a participant whose behavior jeopardizes his or her health or safety, or the
safety of others. In these cases, and
with justifiable cause for the service coordinator’s safety, the service
coordination agency may elect to disenroll such participant without providing
further remedy or technical assistance.
(e) Prior to disenrollment for any of the
above, the service coordination agency proposing to disenroll a participant
involuntarily is required to:
(i) document the reasons for proposing to
disenroll the participant as well as any and all efforts to remedy the
situation; and
(ii) submit the written request to
involuntarily disenroll the participant to HSD, along with supporting
documentation for HSD’s review and determination that the service coordination
agency has provided acceptable grounds for the participant’s disenrollment.
[8.326.10.9 NMAC - Rp, 8.326.10.9 NMAC, 4/1/2021]
8.326.10.10 BISF CONTRACTED ENTITIES AND
CONTRACTORS: Brain
injury services fund (BISF) services are provided through two contractor
components, service coordination and fiscal intermediary agent for BISF HCBS.
A. Service
coordination services: Service coordination services serve a
problem-solving function. They are
intended to resolve a participant’s stated crisis need, ensure service
continuity, prevent fragmentation of services and endeavor to tap into any and
all resources that are appropriate and accessible, including community-based
supports, while resolving the crisis that brought the participant into the
program. The intent of service
coordination is to augment, not replace, the participant's natural supports in
a manner that facilitates independent living and self-determination. All
participants must have a BISF program service coordinator before they can
receive any other BISF program services.
(1) Qualifications for
service coordination: Service
coordination agencies serving the BISF program must ensure the following
pertaining to staff qualifications:
(a) have a current social worker license
in good standing with the New Mexico board of social work examiners; or
(b) have a current registered nurse
license, in good standing from the New Mexico board of nursing; or
(c) have
a bachelor's degree in social work, counseling, nursing, special education or
closely related field plus one-year clinical experience related to the brain
injury population working in any of the following settings:
(i) home
health or community health program;
(ii) hospital;
(iii) private
practice;
(iv) publicly
funded institution or long-term care program;
(v) mental
health program;
(vi) school or school health setting;
(vii) community-based
social service program; or
(viii) other
programs addressing the needs of individuals with brain injury.
(d) With
prior approval from the HSD BISF program manager or designee, exceptions to
service coordinator qualifications can be made; contractors requesting
qualification exceptions must demonstrate that applicant candidates have relevant education, internships or
volunteer experience. Other
qualifications may be:
(i) associates
degree and a minimum of three years of experience in the mental health or brain
injury field; or
(ii) high
school graduation or general educational development (GED) test and a minimum
of five years of experience in the mental health or brain injury field.
(e) All
BISF service coordinators whether subcontracting or employed by a BISF program
contracted agency must meet these requirements and attend continuing education
as determined by HSD.
(2) Scope
of services: Service coordination
includes but is not limited to facilitating eligibility determination for
individuals applying to the BISF; conducting an in-person assessment;
developing an independent living plan (ILP); coordination and documentation of
the delivery of services; maintaining a complete permanent case record for each
participant which includes documentation as prescribed by HSD; and creating a
transition plan for discharge from the BISF program, coordinating with other
case managers, as needed.
(a) Service
coordinators must identify, and resolve known or suspected issues that may have
an impact on the safety and well-being of the participant.
(b) Service
coordinators must evaluate and monitor direct service and implementation of the
ILP through face-to-face contact with the participant at a frequency prescribed
by HSD.
(c) Service
coordination agencies are required to maintain a 24-hour emergency response
system that allows participants to contact the agency and respond to individual
emergency situations within a reasonable amount of time after notification on a
24-hour basis. An emergency response
written policy is to be provided to all program participants.
B. Fiscal
intermediary agent (FIA): The fiscal intermediary agent (FIA) serves as
the intermediary for the arrangement
and payment of brain injury specific home and
community-based services (HCBS). BISF
services are only accessible through the coordination of a BISF program service
coordination agency and are limited to filling a participant’s needs as
outlined in the participant’s independent living plan (ILP), when there is an
imminent risk to the participant’s health and safety.
(1) Qualifications
for FIA: FIA service staff must demonstrate the
following qualifications:
(a) have
a bachelor’s degree in business, social work, counseling, nursing, special
education or closely related field; and
(b) have
experience related to the brain injury population, working in any of the
following settings:
(i) home
health or community health program;
(ii) hospital;
(iii) private
practice;
(iv) publicly
funded institution or long-term care program;
(v) mental
health program; or
(vi) community-based
social service program; or other program addressing the needs of individuals
with brain injuries.
(c) With
prior approval from the BISF program manager or designee, exceptions to FIA
personnel qualifications can be made.
Contractors requesting qualification exceptions must demonstrate
relevant education internships or volunteer experience. Other qualifications may be:
(i) associate
degree and experience in the mental health or brain injury field; or
(ii) high
school graduation or general educational development (GED) test and extensive
experience in the mental health or traumatic brain injury field.
(d) All
BISF FIA staff employed by the agent, must meet these requirements and attend
continuing education as determined by HSD.
Contracted FIA service providers must have the required education and be
duly licensed by the state of New Mexico within their respective disciplines.
(2) Scope
of services:
Fiscal intermediary agent services include but are not limited to the
following activities: maintain a network of providers of brain injury related
services and goods and ensure that subcontracted providers are duly licensed by
the state of New Mexico or otherwise certified within their respective
disciplines; procure goods and arrange contracts and letters of agreement with
vendors and contractors who provide the goods, services and supports; receive
service and goods referral requests submitted by BISF service coordinators for
prior authorization; and arrange for delivery of BISF goods and services.
(a) Prior
to arranging for and funding requested services or goods, the FIA must verify
that other responsible payer source coverage is not available to pay for
services or goods and that the participant has exhausted any other financial
resources.
(b) The FIA must monitor and document service
expenditures for participants receiving BISF HCBS and ensure that coverage does
not exceed the allowable limits set by HSD;
(c) The
FIA must assure that subcontracted providers and vendors are providing the
services and goods as contracted and ensure timely reimbursement to such
providers and vendors.
C. General administrative requirements:
Agencies contracted to provide BISF service coordination or fiscal
intermediary services are required to:
(1) have
and follow confidentiality standards;
(2) maintain
a current business license issued by the state, county or city government if
required;
(3) comply
with all applicable federal or state regulations, policies and procedures that
apply to their business and to their contract with HSD;
(4) demonstrate
financial solvency;
(5) maintain
full professional liability insurance coverage;
(6) establish
and maintain written policies and procedures related to:
(a) service
provision and appropriate supervision;
(b) professional
documentation standards;
(c) training
and education on brain injury; and
(d) grievances
and appeals as outlined in 8.326.10.15 NMAC in a manner that is accommodating
to those living with brain injury and agreeable to the HSD BISF program; and
(7) have
a governing board with at least one external member with a brain injury, a
family member with a brain injury or professional working with brain injury;
(8) maintain
an in-house directory of brain injury resources for each region served.
[8.326.10.10
NMAC - Rp, 8.326.10.10 NMAC, 4/1/2021]
8.326.10.11 CONFLICT OF INTEREST: Contracted entities and
providers, who provide direct BISF services, must avoid conflict of interest or
duplication of services and may not:
A. provide direct intervention
services, such as individual therapy, group therapy, support groups, homemaker
services, personal attendant services, life skills coaching services,
psychosocial rehabilitation services, or duplicate BISF HCBS or fiscal
intermediary services for enrolled BISF participants, when they are also
contracted to provide service coordination services;
B. accept gifts from existing or
potential vendors in exchange for a contract relationship or other favorable
treatment;
C. charge
BISF program participants for their services; and
D. in
no instance shall a service coordination agency or fiscal intermediary agent,
contracted by HSD for BISF program services, direct the provider, vendor or
contractor that shall provide a participant’s services or goods.
[8.326.10.11 NMAC - Rp, 8.326.10.11 NMAC, 4/1/2021]
8.326.10.12 INDEPENDENT LIVING PLAN: An independent living plan
(ILP) is required for each interim service period that includes all the
services, goods, and supports recommended to the participant including
referrals to BISF HCBS and any other potential resources available in the local
community that are needed to resolve the identified crisis. BISF HCBS cannot be initiated until the
service coordinator has included the services in the ILP and completed the appropriate
referrals. The ILP is to be written and
developed by the service coordinator with the participation of the participant
and shall include:
A. person-centered goals and action
steps needed to complete goals;
B. education and support necessary to
reach goals and objectives;
C. number of hours per month the
participant will receive BISF service coordination and other identified BISF services;
D. expected measurable outcomes;
E. time frames for reaching goals and
meeting objectives;
F. plans for discharge or transference
to another program or payer source;
G. identification of all persons,
services or products necessary to reach the participant's goals and accomplish
their objectives; and
H. estimation of cost of services or
goods provided by HCBS.
[8.326.10.12 NMAC - Rp, 8.326.10.12 NMAC, 4/1/2021]
8.326.10.13 BRAIN INJURY SERVICES FUND HOME AND
COMMUNITY-BASED SERVICES: BISF home and community-based services (HCBS)
and goods are for outpatient care administered within the state of New Mexico
and must address the participant’s assessed needs and include the expectation
of individual and family participation.
BISF HCBS are designed to resolve a participant’s identified crisis,
enhance the individual's self-determination and promote independence. BISF HCBS funding can only be used for
services and goods that are documented in the participant’s ILP and or
substantiated by physician’s orders or other required documentation, as
appropriate. As the payer of last
resort, BISF funding may be used for the purchase of authorized services or
goods that are not covered by medicaid, medicare, the special
education-individuals with disability education act (IDEA) program, department
of vocational rehabilitation (DVR), private insurance or other responsible
payer sources. The delivery of all BISF
HCBS will be in accordance with the standards set by HSD.
A. BISF HCBS eligibility requirements:
BISF HCBS can only be provided to program participants who have a
current BISF service coordinator and have met BISF program requirements. Eligibility for BISF HCBS is based upon the
service coordinator’s assessment of participant needs, verification that no
responsible payer source exists, and receipt of supporting medical
documentation, as appropriate to justify the need for a requested service or
good. Referrals for qualifying
participants are submitted to the FIA, who arranges and pays for authorized
goods and services in 90-day increments.
B. Funding limits per participant: There is a maximum yearly and lifetime
coverage for eligible participants as determined by their assessed needs. Funding is also limited by legislative or
departmental appropriation. Coverage
limitations for qualifying participants are as follows:
(1) No
more than the annual budgetary cap per participant as prescribed by HSD, unless
through approved written exception by HSD; this value represents a maximum
amount that may be budgeted and is not a guaranteed annual budget assignment.
(2) $75,000
lifetime maximum for combined services and goods;
(3) $10,000
lifetime limit on environmental modifications; and
(4) only
one emergency housing assistance per participant in a lifetime, unless an
exception is made in writing by the BISF program manager at the HSD.
C. Duration of services: BISF HCBS funding and approved
services are provided in six month increments with the following provisions:
(1) BISF
HCBS are provided as funding limits allow only until other responsible payer
sources are available, or the crisis has been otherwise resolved.
(2) BISF HCBS can only be continued for
one additional interim, up to one year with documentation that the needs being
addressed still exist and cannot be provided by another responsible payer. Continuation of BISF HCBS for requested
services is contingent upon completion of a six-month written recertification
conducted by the participant’s service coordinator in accordance with program
standards. As applicable, this will
include orders from a physician or licensed medical provider stating support
for ongoing services.
(3) BISF HCBS may be extended or continue past the six-month duration,
until a necessary product can be obtained or in the case of environmental
modification and retrofit automobile services, the modification to the
participant's environment or automobile can be completed. Any cause for delay must be recorded by the
service provider in the participant's record and provided to the service
coordination agency. The record must be
updated, until completion of the project or modification has been completed or
the goods ordered are delivered.
(4) Exceptions to the six-month interim timeline beyond two
consecutive interims, may be requested by the service coordination agency in
writing through HSD’s process for extending services and referrals on the basis
of one or more unresolved crises, ongoing participant needs and available
funding.
(5) After
a participant’s BISF HCBS have been inactivated, services may be reestablished
through the BISF service coordinator due to an exacerbated condition or
situation that has caused a critical need that cannot be covered by other
responsible payer sources.
(6) Participants
who are receiving BISF HCBS may be eligible to access additional BISF HCBS
funding, beyond the prescribed limits, if the person has experienced a sudden,
drastic and accelerated change in needs impacting health and safety, such as an
exacerbated medical or psychological condition.
Participants accessing BISF HCBS on an escalated basis will require
medical documentation to establish a higher order of need. Escalated services may or may not be provided
as funding allows on a short-term basis, per program requirements.
D. Freedom
of choice: Each
participant receiving BISF HCBS shall be informed of all available service
providers, vendors or contractors that are eligible to provide the needed
services or goods in their region. The
participant shall be the sole decision maker of who is to provide services or
goods from all eligible entities that could fill his or her needs. The BISF program cannot guarantee that all
services will be available in all regions or that a preferred provider will
agree to work with the program.
E. Service
descriptions: Services
that require physician’s orders include but are not limited to home health
aide, nursing services, neuropsychological evaluations, novel or unconventional
therapies, durable medical equipment over $250, and other non-standard services
and goods. Requested services and goods
cannot be accessed until authorized in writing by the FIA, who arranges and
pays for approved BISF HCBS and goods.
BISF HCBS funding may be used to pay for services and goods that meet
the noted criteria in the following categories, with special requirements, as
noted:
(1) Assistive technology assessment
services: Assistive technology assessment
services are the systematic application of technologies to assist persons
diagnosed with brain injury to improve communication skills and the ability to
perform activities of daily living. An
assistive technology assessment is required to justify the purchase of
assistive technology or adaptive equipment that is needed to address symptoms
of the participant’s brain injury.
Services shall be provided by an individual or agency with a minimum of
a master’s degree in assistive technologies; an individual or agency certified
by the rehabilitation engineering and assistive technologies society of North America
(RESNA); an individual or agency demonstrating a working knowledge of assistive
technologies; or a licensed physician or rehabilitation provider agency. Services shall include assessment,
recommendations and training by a qualified healthcare professional.
(2) Durable medical equipment and
assistive technology: Durable
medical equipment (DME) refers to any equipment that is used to serve a medical
purpose or provides therapeutic benefits to a patient in need because of
certain medical conditions, related to a participant’s brain injury. Assistive or adaptive technology refers to
any "product, device, or equipment, whether acquired commercially,
modified or customized, that is used to maintain, increase, or improve the
functional capabilities” of a person living with brain injury. DME or adaptive equipment is intended to fill
the assessed medical, therapeutic or functional needs of participant and a
prescription and a written assessment provided by a physician or licensed
therapist must be submitted to justify the equipment requested if the cost of
the DME is more than $250.
(3) Environmental modifications: Environmental modifications refer to
alterations required to make the participant’s home more accessible because of
their brain injury and related physical limitations. Environmental modifications include but are
not limited to, widening doorways, installing ramps and modifying
bathrooms. Funds cannot be used to cover
home improvements; expenses related to home maintenance or other repairs that
would otherwise be incurred as a responsible homeowner or tenant; or be applied
toward the purchase of a home. The
following criteria for environmental modifications must be adhered to:
(a) An
assessment for the proposed environmental modification must be done by a
licensed physical or occupational therapist to justify the service.
(b) For
any modification over $250, contractor bids must be obtained by the service
coordinator which must include blueprint, written description of plan and price
itemization for materials and labor, along with any other supporting
documentation.
(c) Only
contractors with a current license in good standing can be engaged to do
environmental modifications.
(d) Funds
for environmental modifications are limited to a $10,000 lifetime maximum.
(e) The
participant shall provide proof of property ownership, and, if residing in or
renting property owned by another party, provide written permission from the
landlord prior to pursuing any BISF funded environmental modification;
(f) The
FIA in collaboration with the participant’s service coordinator shall show
evidence that BISF funding was the most appropriate payer source to fund the
requested environmental modification;
(g) For
instances when costs related to a needed environmental modification cannot be
covered in total by another funding source, documentation of collaboration with
other funding sources must be submitted to the FIA and include:
(i) a
detailed description and plan for the project including total cost;
(ii) the
specific portion to be funded by the BISF program as the payer of last resort;
and
(iii) the
contractor’s written acknowledgment of the specific portion and amount of the
project for which the BISF program is responsible.
(h) All
requests, plans and related documentation for environmental modifications shall
be submitted by the BISF service coordinator for review and written approval by
HSD, prior to submitting a referral.
(4) Home health aide, homemaker or
companion: A home health aide,
homemaker or companion from a licensed agency may be contracted to assist
participants in gaining functional independence with activities of daily
living, performance of general household tasks, and enable the eligible
participant to accomplish tasks he or she would normally do for himself or
herself if he or she did not have a brain injury. Providers of these services must meet the
quality personnel standards as stipulated by the agency and state
licensing. The required license of contractors
providing these services must be in good standing and current. Provision of authorized services must adhere
to the following requirements:
(a) Participants must require regular assistance with
activities and or instrumental activities of daily living, as prescribed by the
HSD BISF program.
(b) Family members, who reside in the same household, cannot
serve as paid caregivers, unless:
(i) the participant and family member reside in a remote area,
where no professional caregiver or respite services are available, and the
needs of the participant prevent the in-home caregiver from engaging in
employment outside the home; or
(ii) the intensiveness of the participant’s
behavioral or mental health needs prevent outside caregivers from entering the
home and administering effective care.
These needs shall be justified in writing through a signed letter from
the participant’s licensed medical or mental health care providers and
submitted to HSD or designated representative for review and approval. Such justification shall be updated annually,
for as long as the participant remains eligible for BISF services.
(c) In-home family caregivers who meet the criteria noted in
Subparagraphs (a) and (b) of Paragraph (4) of Subsection E of 8.326.10.13 NMAC
must be trained and employed by a licensed agency that meets the quality
personnel standards, as stipulated by the agency and state licensing, and
timesheets shall be submitted, as requested.
(5) Initial and emergency housing costs: Assistance
to pay initial or emergency rent, security deposit and utility start-of-service
or one-month maintenance of service charges may be provided as once in a
lifetime occurrence. Documentation
submitted by BISF service coordinators with any housing referral to the FIA
shall adhere to the guidelines below and be maintained in the participant’s
BISF record:
(a) a
completed housing plan worksheet and budget, which includes documentation that
the participant has sufficient resources to sustain ongoing housing expenses
for the chosen housing; documentation that no other payer source was available
to cover the housing expenses; the rental price range that would be sustainable
for the participant; and detail regarding the manner in which initial housing
or utility costs will be paid.
(b) a
copy of a lease or rental agreement letter that contains the name of the
leaser, the address of the property and a contact name and phone number for
verification of rental intent.
(c) start
up and or emergency utility costs shall be submitted to the FIA to be paid
within 90 days of the signed rental agreement.
(6) Nursing care: Brain injury related private duty nursing
services covered by
BISF HCBS must be in compliance with the New Mexico Nurse Practice Act and
provided in the participant’s home under the orders of the participant’s
physician. These services may be
provided by a licensed registered nurse (RN) or a licensed practical nurse
(LPN).
(7) Nutritional consultation: Coverage includes consultation and follow-up with a registered dietician
or nutritionist, who is licensed with the New Mexico board of nutrition and
dietetics; qualified providers may include specialists such as MDs, DOs,
Ph.D.s, RDs, LDs, or DCs.
(8) Physician or medical provider services
for outpatient health insurance:
Coverage of copayments for physician services or the treatment of a
participant’s brain injury or conditions directly related to the brain injury
requires treatment verification by the office of the licensed medical
professional or therapist. Payments of
insurance premiums and or deductibles are not covered by the BISF program.
(9) Prescribed medications: Copayment assistance may be used to
cover prescription medications that are medically necessary to treat symptoms
arising from a participant’s brain injury or directly related conditions.
Reimbursement for this service requires adherence to the following guidelines:
(a) prescription
medications eligible for reimbursement must be listed in the approved BISF
program formulary. Exceptions to the
BISF program formulary must be approved in writing from the HSD BISF program
manager or designee;
(b) participants
may not be reimbursed for prescription medications in cases where the receipt
evidencing purchase is submitted more than 90 days past the date the
prescription was filled;
(c) the
participant must submit the pharmacy print out, which identifies the
participant’s name, the date, doctor's name, name of the medication and the
price paid; and
(d) if
feasible, and the FIA is able to set up an agreement with certain pharmacies,
participants may have scripts filled with the billing sent directly to the FIA
for payment; the service coordinator is responsible for checking receipts
submitted by participants to avoid duplicate payments on those submitted
through the pharmacy.
(10) Professional life skills coaching and organizer
services: This interim service may be accessed to assist
a participant in learning or re-learning life skills that are required in order
to function independently in their home environment, in their job or in their
community. These services are provided
by individuals with appropriate certification and require the provider to
address the cognitive, behavioral or social impairments that are preventing the
return to independent functioning. The
service may include assistance with home organization or management, time
management, records management, and organization and management of finances, as
well as coaching in appropriate social interactions; effective communication
skills; anger management; self-care/health management; pursuit of education or
employment; childcare and parenting skills; accessing and navigating community
resources; mindfulness training and any other cognitive, social, or behavioral
skills identified in the participant’s ILP.
The services of the life skills coach are not to be used as a substitute
for the participant’s task performance.
The services are customized for each participant and are usually
provided in the person's home, place of work or wherever an activity would
normally occur. Services are to be
provided at a frequency that will best facilitate the transfer of needed
skills, following an evaluation conducted by the coach. Life skills may also be provided to family
members to help them adjust to their changed roles and circumstances following
the brain injury of their family member.
Service limitations apply as prescribed by HSD.
(11) Respite care: A participant’s primary caregiver may be
provided temporary respite, if the caregiver lives in the same household as the
participant. Respite may be provided for
a period up to 72 hours per week and may or may not include overnight
hours. BISF HCBS funds cannot be used to
pay for respite care provided by home health aides or salaried employees.
(12) Retrofit automobile: This service is used to modify an automobile
specifically for the use of a participant with brain injury. The service is limited to installation of a
van lift; hand or pedal controls; and modified seating. Funds cannot be used for the purchase of an
automobile or be applied toward the cost of auto repairs or maintenance that
would be otherwise incurred by the responsible vehicle owner or lessee. Any request for retrofit of an automobile
will begin with a referral by the service coordinator identifying a certified
driver rehabilitation specialist (CDRS), who will assess the abilities of the
participant with brain injury, complete an evaluation, make recommendations for
the vendor who will perform the installation, and provide any training on the
use of specialized equipment or controls, once the installation is
completed. The CDRS may or may not be
affiliated with the vendor who completes the installation; a separate referral
may be needed for the vendor completing the installation.
(13) Transportation (public or private): Requests
to cover private or public in-state transportation for participants with brain
injury must adhere to the following guidelines:
(a) Funds may be authorized for mileage
reimbursements for the use of the participant’s private vehicle for the purpose
of getting to medical and therapy care for treatment of conditions directly
related to the brain injury. Approved
mileage reimbursements will:
(i) require prior approval by the BISF
service coordinator for identified destinations and be authorized for payment
by the BISF FIA;
(ii) cover costs of actual mileage at no
more than the current state approved rates;
(iii) not be authorized to pay for gas,
mileage or wear and tear on any other vehicle not privately owned by the
participant with brain injury;
(iv) not cover overnight costs for
participant or caregiver lodging or per diem; and
(v) not be covered for requests submitted
more than 90 days past the date the transportation was provided, or the trip
was taken.
(b) Funds may be used to purchase public
transportation in the form of bus, van or rail passes for participants and
their caregivers.
(14) Therapies and alternative therapies: All therapists providing traditional and
alternative therapy services must hold a current license and be in good
standing from their respective licensing authority. Service limitations on alternative therapies,
such as massage, acupuncture and chiropractic care may apply, as specified by
the HSD. BISF HCBS funds may be used to
cover copayments for medically necessary therapies, as listed below:
(a) outpatient
mental or behavioral health;
(b) physical
therapy;
(c) occupational
therapy;
(d) speech
and language therapy;
(e) massage
therapy;
(f) acupuncture;
and
(g) chiropractic
care.
(15) Other use of BISF HCBS funds: BISF
HCBS funds may be used to provide other limited services in the absence of
another payer source. Those services
provided by a licensed practitioner may require an order or a letter of
recommendation from a licensed physician or therapist. Requests for these services must be submitted
by the service coordinator in writing for written authorization by the HSD BISF
program manager or designee and include:
(a) Special
training and education to the participant and family in the use of tools and
methods needed to promote recovery and independence of the participant.
(b) Neuropsychological
evaluations to determine a course of treatment for a participant who has
already met the BISF program’s eligibility criteria. The participant must present a physician's
order or letter of recommendation for prior authorization, before accessing the
service.
(c) Special
health and dietary items that are needed because of conditions directly related
to the brain injury.
(d) Health and housing advocate through
independent contractors or peer mentors for attendance and advocacy at medical
or therapy appointments or providing assistance in locating safe and affordable
housing.
F. Providers
or vendors of BISF HCBS sub-contracted by the FIA may not charge program
participants for services already arranged and authorized through the BISF,
unless the program has authorized direct reimbursement to the participant.
G. Only the HSD BISF program manager or
designee can make exceptions or waivers of requirements regarding the provision
of BISF HCBS with the following stipulations:
(1) requests
for waivers to the provisions and services provided by the BISF program must be
made by the service coordination agency in writing;
(2) requests
must have accompanying documentation justifying the exception; and
(3) written
approval from HSD must be placed in the participant’s record by both the FIA
and the service coordination agency.
[8.326.10.13 NMAC - Rp, 8.326.10.13 NMAC, 4/1/2021]
8.326.10.14 NON-COVERED
SERVICES AND GOODS:
Costs not covered by BISF HCBS include:
A. Dental
exams, visits, procedures or equipment;
B. Optical
exams, visits, glasses, lenses or other equipment;
C. Hearing
exams, visits or aids or other equipment;
D. Experimental
therapies;
E. Computers
and internet;
F. Cell phones or
cell phone carrier service;
G. Organizational
supplies;
H. Service animals,
certification or training of service animals, veterinary, grooming, boarding or
maintenance costs;
I. Health
insurance deductibles or premiums; and
J. Institutional care, nursing facility or hospital care
costs.
[8.326.10.14
NMAC - Rp, 8.326.10.14 NMAC, 4/1/2021]
8.326.10.15 SERVICE AUTHORIZATION AND
REIMBURSEMENT: Funding for BISF service
coordination, BISF HCBS and fiscal intermediary agent services is based upon
trust fund revenues and legislative or departmental appropriation. Billings and receipts for all approved
goods, services and supports, shall be submitted for payment or reimbursement
within 90 days of the service date, by the participant, service coordinator or
vendor, following all HSD BISF program instructions. Reimbursement for goods, services and
supports are made at a predetermined reimbursement rate. The HSD reserves the right to approve
or disapprove any and all vendors or subcontractors used by the BISF HCBS
fiscal intermediary agent.
[8.326.10.15
NMAC - Rp, 8.326.10.15 NMAC, 4/1/2021]
8.326.10.16 GRIEVANCE AND APPEALS PROCESSES FOR
THE BRAIN INJURY SERVICES FUND PROGRAM: The BISF program allows
for a grievance or complaint process that affords program participants the
opportunity to register grievances or complaints concerning the provision of
services that are administered through the BISF program.
A. Grievances:
(1) Program
participants may register complaints with the service coordination and FIA
contractors.
(2) Individual BISF contractors will
have written grievance procedures approved by HSD, which provide the
participant or their representative with a process for expressing
dissatisfaction with the program services.
(3) The contractor’s written grievance
procedure is to be available upon request by program participants, HSD or its
assigns.
B. Appeals:
(1) If the participant or their representative do not agree with the
outcome of a formal grievance filed and reviewed at the BISF contracted agency,
they may appeal, in writing, to the HSD BISF program manager.
(2) The HSD BISF program manager or designee will review the written
appeal along with any supporting documentation as applicable and will respond
in writing to the participant filing the appeal within 30 days with
notification of the outcome to the provider agencies involved.
[8.326.10.16 NMAC - Rp, 8.326.10.15 NMAC, 4/1/2021]
HISTORY
OF 8.326.10 NMAC: [RESERVED]
History of Repealed Material:
8.326.10 NMAC -
Traumatic Brain Injury Trust Fund Program (filed 10/25/2007) repealed effective
4/1/2021.
Other History:
8.326.10 NMAC - Traumatic Brain Injury Trust Fund Program (filed 10/25/2007) was replaced by 8.326.10 NMAC - Brain Injury Services Fund Program, effective 4/1/2021.