Medical Assistance Division Managed Care Policy Manual

Medical Assistance Division

Managed Care Policy Manual

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Contents 
 General Provisions...................................................................................................... 1 
1.  General Information .................................................................................................... 1 
 Provider Network ........................................................................................................ 2 
1.  Service Termination and Provider Closure .................................................................. 2 
2.   MCO-Initiated Provider Network Closures and Reductions ......................................... 3 
3.   Provider Monitoring ..................................................................................................... 4 
4.   Requirements for Provider Enrollment ........................................................................ 4 
5.   Institutional Type Providers ......................................................................................... 8 
6.   Providers Whose Services are Based on Orders and Referrals ................................ 10 
7.   Rendering Providers ................................................................................................. 11 
8.   Using the Web to Verify Attending, Ordering, Referring, Rendering or Prescribing 
Providers .................................................................................................................. 14 
9.   Exclusions ................................................................................................................ 17 
10.   General Information on the Requirements based on Procedure Codes .................... 18 
11.   Appendices ............................................................................................................... 23 
11.1.   Notification of Change in Services – Notification of Transition ...................................24 
11.2.  Transition Plans Narrative .........................................................................................25 
11.3.   Transition Plan A ......................................................................................................27 
11.4.  Transition Plan B ......................................................................................................29 
11.5.  Definitions .................................................................................................................31 
  Member Education .................................................................................................... 32 
1.   Policies and Procedures ........................................................................................... 32 
2.   Member Handbook ................................................................................................... 33 

3.   Provider Directories .................................................................................................. 35 
4.   Member Identification Card ....................................................................................... 35 
5.   Member Advisory Board ........................................................................................... 35 
 Care Coordination ..................................................................................................... 37 
1.   General Information .................................................................................................. 37 
2.   Care Coordination Functions .................................................................................... 37 
3.   Health Risk Assessment ........................................................................................... 40 
4.   Comprehensive Needs Assessment ......................................................................... 42 
5.   Community Benefit Service Questionnaire ................................................................ 47 
6.   CNA Reassessments ................................................................................................ 48 
7.   Comprehensive Care Plan Requirements ................................................................. 49 
8.   Staffing Requirements and Delegations .................................................................... 54 
9.   Engagement of Members .......................................................................................... 57 
10.   MCO Care Coordination with 1915(c) HCBS Waivers: Developmental Disabilities 
(DD), Mia Via, and Medically Fragile (MF) Waivers ................................................... 58 
11.   Overview of Medicaid 1915(c) HCBS Waiver Programs ............................................ 59 
12.   MCO Care Coordination Activities and the 1915(c) HCBS Waivers Service Plan (ISP 
or SSP) ..................................................................................................................... 61 
13.   MCO Care Coordination Activities for MF EPSDT (Non-Waiver) Members Case 
Managed by the MFW Case Management Agency ................................................... 63 
14.   Transitions from the HSD Non-Medicaid Brain Injury Services Fund to a Centennial 
Care MCO ................................................................................................................ 64 
15.  Appendix ................................................................................................................... 66 
15.1.  Health Risk Assessment ........................................................................................... 66 
  Transitions of Care.................................................................................................... 68 

1.   General Information .................................................................................................. 68 
2.   Transitions of Care.................................................................................................... 69 
3.   Transitions of Care Requirements ............................................................................. 70 
4.   Transition of Care Requirements for Pregnant Women ............................................. 71 
5.   Transfer from the Health Insurance Exchange .......................................................... 72 
6.   Transitions of Care for Members Moving from a Higher LOC to a Lower LOC .......... 72 
7.   Transitions of Members Turning 21 Years of Age ..................................................... 73 
8.   Transition for Members changing MCOs while Hospitalized ...................................... 74 
9.   Transition for Members Changing MCOs during Major Organ and Tissue 
Transplantation Services .......................................................................................... 75 
10.   Transition for Members Changing MCOs while receiving Outpatient Treatment for 
Significant Medical Conditions .................................................................................. 75 
11.   MCO Requirements for Members Transitioning between MCOs ............................... 76 
12  Transitions of Care for Justice Involved Members ..................................................... 77 
13  Transitions of Care for Substance Exposed infants ................................................... 78 
  Nursing Facilities (NFs) ............................................................................................. 80 
1.   General Information .................................................................................................. 80 
2.   NF Procedures for Requests for Prior Approval ........................................................ 80 
3.   Pre-Admission Screening and Resident Review (PASRR) ........................................ 80 
4.   Level of Care Packet for Nursing Facilities ................................................................ 83 
5.   Denial of Requests for NF LOC Determinations ........................................................ 85 
6.   Reserve Bed Days .................................................................................................... 86 
7.   Initial Determination, Redetermination, and Pending Medicaid Eligibility ................... 87 
8.   Care Plan and Emergency Preparedness ................................................................. 88 
9.   Retroactive Medicaid Eligibility .................................................................................. 89 

10.   Re-Admission Reviews ............................................................................................. 89 
11.   Current/Retrospective Reviews ................................................................................. 90 
12.   Transfer from Another NF ......................................................................................... 90 
13.   Changes in the LOC ................................................................................................. 91 
14.   Discharge Status ...................................................................................................... 91 
15.  Re-Review, Reconsideration, Appeal, Administrative Hearing .................................. 92 
16.   Communication Forms .............................................................................................. 94 
17.   External Audits of NF LOC Determinations ............................................................... 94 
18.   MCO Internal Audits of NF LOC Determinations ....................................................... 94 
19.    RESERVED ............................................................................................................. 94 
  Community Benefits .................................................................................................. 95 
1.   General Information .................................................................................................. 95 
2.   Definitions ................................................................................................................. 96 
3.   Nursing Facility Level of Care ................................................................................... 98 
4.   Continuous NF LOC for Certain Eligible Members .................................................... 98 
5.   External Audits of NF LOC Determinations ............................................................... 99 
6.   MCO Internal Audits of NF LOC Determinations ....................................................... 99 
7.   Registration for the CB for NOME Members ........................................................... 100 
8.   Allocation Process .................................................................................................. 102 
9.   Eligibility .................................................................................................................. 104 
10.   Closing/Inactivating an Allocation ............................................................................ 105 
11.   Registrant Notice Requirements ............................................................................. 105 
12.   Undeliverable Notice ............................................................................................... 106 
  Agency-Based Community Benefits (ABCB) ........................................................... 107 

1.   General Information ................................................................................................ 107 
2.   Definitions ............................................................................................................... 109 
3.   ABCB Services Requirements ................................................................................ 111 
4.   ABCB Covered Services ......................................................................................... 112 
5.   Adult Day Health Services ...................................................................................... 112 
6.   Assisted Living Facility (ALF) .................................................................................. 115 
7.   Behavior Support Consultation (BSC) ..................................................................... 122 
8.   Community Transition Services (CTS) .................................................................... 126 
9.   Emergency Response Services (ERS).................................................................... 128 
10.   Employment Supports ............................................................................................. 131 
11.   Environmental Modifications ................................................................................... 136 
12.   Home Health Aide (HH Aide) .................................................................................. 139 
13.   Nutritional Counseling ............................................................................................. 142 
14.   Personal Care Services (PCS) ................................................................................ 146 
15.  Private Duty Nursing (PDN) for Adults .................................................................... 176 
16.  Nursing Respite Services ........................................................................................ 182 
17.   Respite Services ..................................................................................................... 185 
18.  Skilled Maintenance Therapies ............................................................................... 190 
19.  Occupational Therapy (OT) for Adults ..................................................................... 191 
20.  Physical Therapy (PT) for Adults............................................................................. 195 
21.  Speech Language Therapy (SLT) for Adults ........................................................... 200 
  Self-Directed Community Benefits (SDCB) ............................................................. 207 
1.  Purpose .................................................................................................................. 207 
2.  Guiding Principles ................................................................................................... 208 

3.  Philosophy of Self Direction .................................................................................... 208 
4.  Definitions ............................................................................................................... 209 
5.  SDCB Member Rights ............................................................................................. 212 
6.  SDCB Member Responsibilities .............................................................................. 212 
7.  SDCB Supports ...................................................................................................... 216 
8.  Planning and Budgeting for SDCB Covered Services ............................................. 226 
9.  SDCB Qualifications for all SDCB Employees, Independent Providers, Provider 
Agencies and Vendors ............................................................................................ 229 
10.  SDCB Covered Services ......................................................................................... 231 
11.  Self-Directed Non-Covered Services ...................................................................... 264 
12.  SDCB Budget and Care Plan Approval Process ..................................................... 264 
13.  Initial SDCB Budget Determination Process ........................................................... 265 
14.  Initial SDCB Care Plan Approval Process ............................................................... 265 
15.  Annual SDCB Budget Determination and Approval Process ................................... 266 
16.  Annual SDCB Care Plan Development and Approval Process ................................ 267 
17.  SDCB Budget and Care Plan Approval Process for Individuals Who Transitioned from 
the MI VIA Waiver Program .................................................................................... 267 
18.  Denials, Revisions and Reconsiderations of the SDCB Care Plan .......................... 268 
19.  SDCB Care Plan Review Criteria ............................................................................ 270 
20.  Implementation of the SDCB Care Plan .................................................................. 270 
21.  Transitions, Terminations, and Reinstatement Processes ....................................... 276 
22.  Appendices ............................................................................................................. 279 
22.1.  SDCB Range of Rates Chart .................................................................................. 280 
22.2.  SDCB Vendor Credentialing Requirements ............................................................ 283 
22.3      Employee Credentialing Requirements Grid ............................................................ 290 

22.4.  Vendor Toolkit: Invoices .......................................................................................... 291 
22.5.  Employee Toolkit: Timesheets ................................................................................ 294 
 RESERVED ............................................................................................................ 297 
 Marketing ................................................................................................................ 298 
1.  General Information ................................................................................................ 298 
 Patient-Centered Initiatives ..................................................................................... 304 
1.  Broad Standards ..................................................................................................... 304 
 ABP Medically Frail and ABP Exempt ..................................................................... 306 
1.   General Information ................................................................................................ 306 
2.  Determination of Medically Frail Diagnosis ............................................................. 306 
3.  ABP Exempt Approval ............................................................................................ 307 
4.  Appendices ............................................................................................................. 307 
4.1.   ABP Benefit Chart .................................................................................................. 308 
4.2.  Alternative Benefit Plan-Exempt Medically Frail Conditions List .............................. 320 
4.3.   Chronic SUD Criteria Checklist .............................................................................. 323 
4.4.   SMI Criteria Checklist ............................................................................................ 324 
4.5.  SMI-SED Criteria .................................................................................................... 325 
  School-Based Health Centers ................................................................................. 329 
1.  General Information ................................................................................................ 329 
2.  Initial Certification Process ...................................................................................... 331 
3.  Recertification Process ........................................................................................... 332 
4.  Adolescent Confidential Services and Suppression of Explanation of Benefits (EOBs)
 ............................................................................................................................... 335 
 Indian Health Services, Tribal Health Providers, and Urban Indian Providers (I/T/U)


1.  FQHC/Tribal 638 Claims Processing (Alamo and Pine Hill) .................................... 337 
 Fair Hearings .......................................................................................................... 338 
1.  Administrative Hearings .......................................................................................... 338 
2.  The Member’s HSD Administrative Hearing ............................................................ 339 
3.  Appendices ............................................................................................................. 349 
3.1.  MCO Checklist – Acknowledgement of Receipt of a Member-Filed Grievance ........ 350 
3.2.  MCO Checklist for Member Grievance Final Letter ................................................. 352 
3.3.  MCO Checklist for Notice of Action Letter to Member ............................................. 353 
3.4.  MCO Checklist for Notice of Action Letter to Member Regarding VAS .................... 357 
3.5.  MCO Checklist for the Acknowledgements of Member Appeals .............................. 358 
3.6.  MCO Checklist for Letter Informing the Member of a Delay for an Appeal Decision 361 
3.7.  MCO Checklist for the MCO Member Appeal Final Decision Letter ......................... 362 
 Managed Care Reporting ........................................................................................ 365 
1.  General Information ................................................................................................ 365 
2.  General Requirements ............................................................................................ 365 
3.  MCO Reporting and Intake ..................................................................................... 365 
4.  Report Rejection ..................................................................................................... 366 
5.  MCO Report Resubmission .................................................................................... 366 
6.  Report Revisions .................................................................................................... 367 
7.  System Availability Reporting .................................................................................. 368 
8.  Appendices ............................................................................................................. 368 
8.1.  Centennial Care MCO Reports ............................................................................... 369 
8.2.  Systems Availability Incident or Event Report ......................................................... 374 
 Quality .................................................................................................................... 375 

1.  Performance Improvement Projects (PIPs) ............................................................. 375 
2.  Provider Satisfaction Survey ................................................................................... 375 
3.  Critical Incident Reporting ....................................................................................... 376 
4.  Appendix ................................................................................................................. 377 
4.1.  Centennial Care Reporting Survey Template .......................................................... 378 
 Program Integrity .................................................................................................... 382 
1.  General Information ................................................................................................ 382 
2.  Fraud, Waste and Abuse Requirements ................................................................. 382 
3.  Suspension of Medicaid Payments for Credible Allegations of Fraud ...................... 386 
4.  Adverse Action Reporting ....................................................................................... 387 
5.  Recipient Explanation of Medical Benefits .............................................................. 388 
6.  Fraud, Waste and Abuse Compliance Plan ............................................................. 388 
 Pharmacy ............................................................................................................... 389 
1.  General Information ................................................................................................ 389 
 Manual Acronyms ................................................................................................... 403 
 
   

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Section 1: General Provisions

Revision dates: August 15, 2014; March 3, 2015

Effective dates: January 1, 2014

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1. General Provisions

1.1. General Information

The purpose for the Managed Care Policy Manual (the Manual) is to provide a reference for the policies

established by the New Mexico Human Services Division (HSD) for the administration of the Medicaid

managed care program and to provide direction to the managed care organizations (MCOs) and other

entities providing services under managed care.

The Manual was developed by the Medical Assistance Division (MAD) of HSD to assist MCOs in the

administration of the managed care program. These policies establish general operating procedures to

assist in the day to day management of the managed care program. This Manual should be used as a

reference and a general guide. It is a resource for interpreting the Medicaid Managed Care Services

Agreement (the Agreement) and New Mexico Administrative Code (NMAC) rules pertaining to managed

care.

The provisions of the Manual reflect the general operating policies and essential procedures of the

managed care program, are not all inclusive, and may be amended or revoked at any time by the HSD.

These policies may be amended and will be reviewed on a periodic basis to determine if changes are

necessary. The Manual will be updated on a regular basis, and HSD reserves the right to change, modify,

or supersede any of these policies and procedures with or without notice at any time.

As policies are revised throughout the year, they will be incorporated into the Manual. The Manual may

be viewed or downloaded from MAD’s home page website at www.hsd.state.nm.us. A summary list of

the policy revisions will also be posted on line each year.

If there is a conflict between the Manual and the Agreement or NMAC rules, the Agreement and NMAC

rules will control. The Manual is intended to provide guidance; it is not intended to, nor does it create,

any rights that are not contained in the Agreement or NMAC rules.

The Manual will be issued and maintained by HSD. It is the responsibility of all members and entities

affiliated with Medicaid managed care in New Mexico to review and be familiar with the Manual and

any amendments.

If you have any questions about the application of any policy, you should contact the Medical Assistance

Division at 505-827-3100.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

2 | P a g e

2. Provider Network

2.1. Service Termination and Provider Closure

Anticipated changes in the MCO provider network shall be reported to the MAD and Behavioral Health

Services Division (BHSD) Contract Managers in writing within 30 calendar days prior to the change, or as

soon as the MCO knows of the anticipated change. Unexpected changes shall be reported within five

calendar days of the MCO’s knowledge about the change.

Anticipated Changes

Notification

30 Calendar Days

Narrative

10 Calendar Days from date of Notification

Transition Plan A (Overall)

15 Calendar Days from date of Notification

(if change is significant)

Transition Plan B (Member-Specific)

15 Calendar Days from date of Notification

(if change is significant)

Unanticipated Changes

Notification

5 Calendar Days

Narrative

10 Calendar Days from date of Notification

Transition Plan A (Overall)

15 Calendar Days from date of Notification

(if change is significant)

Transition Plan B (Member-Specific)

15 Calendar Days from date of Notification

(if change is significant)

The MCO is required to submit a Notification, Narrative, Transition Plan A, and Transition Plan B as

appropriate, to its Contract Manager on anticipated changes to the network. Refer to the appendices

included in this section for HSD templates. The Manager for either the Behavioral Health (BH) Unit or

the Long-Term Services and Supports (LTSS) Unit shall be copied on any network change related to

either BH or LTSS. Notification is expected whenever a provider informs the MCO, or when the MCO

learns through means other than provider notification, of its intent to change or terminate a service(s).

Notification is also expected if a service provider becomes incapable of performing a contracted service.

In all instances, the MCO is expected to report how the changes will affect the service delivery system,

which may result in the need for members to transition from one service provider to another.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

3 | P a g e

In both expected and unexpected changes in the network, the MCO shall assess the significance of the

change or closure within 10 calendar days of confirmation by the provider. If the MCO determines the

change will not have a significant impact on the system, the Narrative template must be submitted

within 10 calendar days from the date of notification of change or closure to the Contract Manager. In

the Narrative, the MCO must explain all factors considered in making a determination that the change

will not significantly impact the system and provide assurances that all members will be transitioned to

new providers (if applicable). If the MCO determines the change or closure will significantly impact the

delivery system, the MCO is required to submit Transition Plan A (Overall) and Transition Plan B

(Client-Specific) to the Contract Manager within 15 calendar days of the official Notification and

Narrative to HSD. In the event HSD determines a network change is significant, the MCO will be required

to submit all transition information as requested.

Transition information will be submitted on the templates provided by HSD with all columns completed.

The Narrative will be submitted in text format. Updates will be submitted every other week after the

initial submission. A final update will be submitted when all members are transitioned. The Notification,

Narrative, and Transition Plan A will be submitted via email to the HSD Contract Manager. Transition

Plan B will be submitted by fax or via a secure website as determined by the MCO and HSD. The HSD

Contract Manager will review and approve the official Notification, Narrative, and Transition Plan A and

will monitor and provide feedback on Transition Plan B.

If the submitted transition plan documents are incomplete, with the exception of Plan B, HSD will reject

the reporting and monetary penalties may apply per Section 7.3.3.6.5 of the Medicaid Managed Care

Services Agreement.

2.2. MCO-Initiated Provider Network Closures and Reductions

The MCOs will submit a written request to HSD regarding a significant change in the MCO’s provider

network to include either closure or reduction of providers. A significant change is defined as:

• Affecting more than 100 members statewide;

• Affecting more than 100 members in urban area;

• Affecting more than 50 members in rural area;

• Affecting more than 25 members in frontier area; and/or

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

4 | P a g e

• Limits or removes members’ choice of providers, (e.g., closure of BH network, in rural and frontier

areas).

The request must be submitted at least 60 calendar days prior to the MCO’s intended action.

• The request must include a completed Notification form and provide justification for the closure or

reduction of the specific provider network.

• The MCO must submit a current Geographical Access (Geo/Access) report demonstrating member

access and include the accessibility overview, map, and analysis of the provider network.

• HSD will review and provide the MCO with a written approval or denial within 10 business days.

• At HSD’s discretion, the MCOs may be required to submit all transition plan documents.

2.3. Provider Monitoring

HSD/MAD monitors provider access and network adequacy in a variety of ways and through various

reports. The following methods are utilized to monitor MCO provider access and network adequacy:

• Provider Satisfaction Survey;

• Member Satisfaction Survey;

• Secret Shopper Survey;

• Consumer Assessment of Healthcare Providers and Systems (CAHPS) results;

• External Quality Review Organization (EQRO) Reviews;

• MCO Call Center Reports;

• Member Grievances & Appeals Report;

• Primary Care Physician/ Primary Care Provider (PCP) Report;

• Geo/Access Report;

• Network Adequacy Report; and

• Ad Hoc Reports.

2.4. Requirements for Provider Enrollment

In considering provider enrollment, it is important for the MCO to understand there are many instances

when claims cannot be paid, if the billing provider, rendering, referring, ordering, or attending physician

or other practitioner is not enrolled and active with a status of 60 or 70. All managed care network

providers, including network providers of an MCO subcontractor, must be enrolled through a Provider

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

5 | P a g e

Participation Agreement (PPA) with the State Medicaid Agency. MAD may require that some

“non-network” providers enroll based on the number of services rendered to New Mexico Medicaid

recipients or other criteria.

Each MCO must submit a monthly listing of its network providers including the network providers of its

subcontractors. This list is due by the tenth day of each month, reflecting the network providers for the

previous month, and must include the following:

• Provider Name;

• Provider National Provider Identifier (NPI);

• Provider Taxpayer Identification Number (Social Security Number [SSN] or Federal Employer

Identification Number);

• Provider Location Address; and

• If provider receives direct reimbursement from MCO or is employed by a provider receiving the

payment.

The Patient Protection and Affordable Care Act (PPACA) Title 42, Part 455 of the Code of Federal

Regulations requires attending, ordering, referring, rendering, and prescribing providers to be enrolled

in the Medicaid program in order to meet PPACA program integrity requirements designed to ensure all

attended, prescribed, ordered, referred, or rendered services, items, and admissions for Medicaid

beneficiaries originate from properly-licensed providers who have not been excluded from Medicare or

Medicaid. A provider who is enrolled through a PPA with MAD only as a fee-for-service (FFS) provider,

only as a managed care provider, or who is enrolled as both FFS and managed care is considered to be

“enrolled with Medicaid” for these purposes.

Therefore, the expectation is that most services and items will only be paid by the Medicaid program if

the individual provider who attends, prescribes, orders, refers, or renders a service or item is identified

on the claim and is enrolled in the Medicaid program. Otherwise, the claim will be denied in accordance

with Federal requirements.

This requirement now applies to both the Medicaid FFS program and to the Medicaid MCOs. Even with

the implementation of these requirements, FFS and the MCOs will still be required to continue

implementing more changes in the near future, such as:

• Including prescribing providers on pharmacy claims.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

6 | P a g e

• Ensuring we are meeting Centers for Medicare & Medicaid Services (CMS) expectations for Indian

Health Services (IHS) and Federally Qualified Health Centers (FQHCs), which may have changed since

the previous CMS review.

• Working towards including rendering providers on more BH services and home- and

community-based services (HCBS) developmentally disabled (DD) waiver services. (We may also

begin enrolling opticians, hearing aid testers, and other individuals who provide services within a

health care business entity. We are expanding our type and specialty listings to accommodate this

action.

• The MCOs should allow certified-nurse practitioners, clinical nurse specialists and certified nurse-

midwives who have been granted parity with physician privileges at health facilities to admit,

discharge, and authorize continued patient care.

Under these requirements, it is possible that some practitioners will need to enroll in the Medicaid

program; otherwise, the recipient may have to change individual providers in order for their services

to be ordered, referred, prescribed, or attended by a Medicaid enrolled provider.

There are also some providers who are members of groups, agencies, and other facilities who have

not enrolled individually as a member of the group, agency, or facility. To a lesser extent, there may

be some individual providers who have not enrolled in the Medicaid program because they do not

bill Medicaid, but who, never-the-less, order or prescribe services for the recipient that will be billed

to Medicaid by other providers as a result of the order or prescription.

• MAD has developed, and made available on the Conduent New Mexico Medicaid Web Portal at

https://nmmedicaid.portal.conduent.com/webportal/providerSearch a look-up tool to help

providers obtain the NPI of a rendering, prescribing, ordering, referring, or attending provider. The

instructions for using this web portal tool and contact information for the Conduent Provider

Relations staff, are included in this document.

Providers should use this tool to determine if any services they are providing to Medicaid recipients

are based on prescriptions, orders, or referrals from a provider who is not enrolled in the Medicaid

or managed care program.

Providers should also use this tool to determine if any provider or practitioner on their staff needs to

be enrolled and to immediately begin the enrollment process if necessary.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

7 | P a g e

• MAD allows provider enrollment as a Medicaid provider solely for the purpose of establishing

appropriate enrollment for the services they order, refer, or prescribe without having to commit to

seeing all Medicaid patients or even any Medicaid patients.

While discriminatory practices towards recipients are not allowed by State and Federal rules, a

provider can still choose to limit his or her practice and participation in the Medicaid program in

ways that are not discriminatory. Such limitations could include treating emergency situations only,

only seeing recipients who are dually eligible for Medicare, limiting the number of patients or

recipients seen, or to only see existing recipients without taking new patients.

This information may be useful to a provider who is hesitant to enroll in the Medicaid program.

Hospital, Residential, Nursing Facility (NF), HH, and Hospice Claims

The essential requirements are:

• The attending provider must be reported on the Universal Billing (UB) format claim for the

following:

o Inpatient hospital claims;

o Hospice claims; and

o Home health agency (HHA) claims (referring or ordering provider in the attending field).

• NF and intermediate care facilities for individuals with intellectual disabilities (ICF-IID) claims

(referring or ordering provider in attending field;

• Residential facility claims (accredited residential treatment center [ARTC], RTC, and Group Homes)

(referring or ordering provider in the attending field);

• The rendering provider must be reported at the claim header level or on all lines on an outpatient

hospital claim;

• A referring or ordering provider must be reported on an outpatient hospital claim when the service

is the result of a referral; and/or

• If any of these providers submit claims on the CMS 1500 format, such as the physician component

that corresponds to an inpatient or outpatient hospital claim, the requirements for rendering

provider on the CMS 1500 format must be followed.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

8 | P a g e

Referring or Ordering Providers on Claims

The essential requirements are:

• When the service provided is the result of a referral from another practitioner, that provider should

be reported as the Referring or Ordering provider.

• In most instances, the MCO will not know if the service was based on a referral or not; therefore, in

most instances, a referral cannot be required. Instead the provider must be relied upon to follow

the instructions. However, there are certain types of providers whose services are performed only

upon an order or referral from another provider such as independent laboratories, radiology

facilities, suppliers of medical equipment, medical supplies, and oxygen. So it is possible to make the

Referring or Ordering provider mandatory under these circumstances as indicated in this document.

Rendering Providers on Claims

The essential requirements are:

• The rendering provider must be identified for most services.

• Exceptions and special circumstances are described in this document.

2.5. Institutional Type Providers

Specific Provider Reporting Requirements

• HHA Claims; NF Claims: the ordering provider’s NPI must be indicated in the attending provider NPI

field.

• Hospice Claims, Residential Provider claims (ARTC, RTC, and Group Homes): the attending

provider’s NPI is required.

• Hospital Inpatient Claims (including specialty hospitals): the attending provider’s NPI is required.

See below for requirements for outpatient hospital claims.

• Hospital Outpatient claims (Including specialty hospitals): the rendering provider’s NPI must be

reported on hospital outpatient claims. It may either be reported at the header level (if a single

provider is the rendering provider) or at the line level (if there are different rendering providers for

each service or line). Or they may always choose to report at the line level.

In many hospitals, the rendering provider may be a resident, an intern, or a supervised nurse,

technician, or other individual who cannot enroll as a provider in their own right. In these situations,

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

9 | P a g e

the provider overseeing the services for the recipient may be considered the rendering provider and

reported as such.

Even though one may think of a lab code or radiology code, or some other service codes on the

claim as not being performed by the provider, but rather by a lab or radiology technician, the

provider overseeing the service for the recipient is still to be reported as the rendering provider on

that line.

Correct Placement of Information on Claims

Attending Physicians for Inpatient Hospitals, Hospice Providers, Ordering Physicians or HHAs NFs, ICF-

IID, and Residential Facilities

Paper UB format claim: Report the names and NPI in form locator 76 (Attending Provider Name

and Identifiers)

Electronic 837 I claim: Report the names and NPI in loop 2310A

Data Element NM 101 Attending Provider = “71”

Data Element NM 103 Attending Provider Last Name

Data Element NM 104 Attending Provider First Name

Data Element NM 108 Identification Code Qualifier “XX”

Data Element NM 109 Attending Physician Primary Identifier NPI

Referring or Ordering Physicians (or other Providers), Reported when Applicable

Paper UB format: Report the NPI and name of the referring or other provider in Field

Locator 78 (Other Physician’s Name and Identifier)

Electronic 837I The following loop, segment, and element places are used to report the referring provider’s NPI and

name, depending on whether reporting is being done at the header or line level

Referring Provider – 2310F (Header)/2420D (Line), Data Element NM101 = “DN”

Referring Provider Last Name – 2310F (Header)/2420D (Line), Data Element NM103

Referring Provider First Name – 2310F (Header)/2420D (Line), NM104

Referring Provider’s NPI – 2310F (Header)/2420D (Line), NM108 = “XX”

Referring Provider’s NPI – 2310F (Header)/2420D (Line), NM109

Referring or ordering providers are to be reported on claims when the service or item is the result of a

referral or an order.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

10 | P a g e

Rendering providers must be reported on claims for professional services such as reading or interpreting

the results of an anatomical laboratory service or radiological images. Rendering providers may either

be reported at the header level (if a single provider is the rendering provider) or at the line level.

The rendering, referring, or ordering provider may be a resident, intern, supervised nurse, technician, or

other individual not typically enrolled as a provider in their own right. In these situations, the supervising

provider may be considered the rendering provider, referring, or ordering provider, as appropriate, and

reported as such.

2.6. Providers Whose Services are Based on Orders and Referrals

Specific Provider Reporting Requirements

For the Medicaid program, MAD does not distinguish between an ordering and referring provider;

information may be placed in either the ordering or referring provider fields.

The following providers should always have an ordering or referring provider for their services or items:

• Clinical diagnostic laboratories including clinical labs, diagnostic labs for physical tests and

measurements, clinical labs with radiology, and other diagnostic laboratories.

• Hearing aid dealers, IV infusion services, opticians and other eyeglass dispensers, and medical supply

and durable medical equipment (DME) companies.

• Occupational therapists, orthotists, physical therapists, prosthetists, speech and language

pathologists, and rehabilitation centers.

• Radiology and radiation treatment facilities.

MAD recognizes that some therapists can self-refer; that is, upon seeing and evaluating a recipient,

they may refer the recipient to themselves for treatment. When this occurs, the therapist must

report himself or herself as the referring provider, as well as the rendering provider.

Sometimes the referring, ordering, or prescribing provider may be a resident, intern, or supervised

nurse, technician, or other qualified individual who cannot enroll as a provider in their own right. In

these situations, the supervising provider may be considered the rendering provider and reported as

such.

When a laboratory, radiology, or diagnostic test is for or includes a professional component for

reading or interpretation of the results, the rendering provider must be provided in addition to the

referring or ordering provider.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

11 | P a g e

Correct Placement of Information

Referring or Ordering Physicians (or other Provider), Reported when Applicable

Paper CMS 1500 format: Report the NPI of the referring or ordering provider in Field Locator 17b

(Other Physician’s Name and Identifier)

Electronic 837P: The following loop, segment, and element places are used to report the

referring provider’s NPI and name, depending on whether reporting is

being done at the header or line level

Referring Provider – 2310A (Header)/2420F (Line), Data Element NM101 = “DN”

Referring Provider Last Name – 2310A (Header)/2420F (Line), Data Element NM103

Referring Provider First Name – 2310A (Header)/2420F (Line), NM104

Referring Provider’s NPI – 2310A (Header)/2420F (Line), NM108 = “XX”

Referring Provider’s NPI – 2310A (Header)/2420F (Line), NM109

Rendering Physician or Other Provider - Report on all Professional Services

Paper CMS 1500: Report the NPI of the rendering provider in Field Locator 24 J lower line

Rendering Provider ID number

Electronic 837P: The following loop, segment and element places are used to

report the rendering provider’s NPI and name, depending on whether

reporting is being done at the header or line level

Rendering Provider – 2310B (Header)/2420A (Line), Data Element NM101 = “82”

Rendering Provider Last Name - 2310B (Header)/2420A (Line), Data Element M103

Rendering Provider First Name – 2310B (Header)/2420A (Line), NM104

Rendering Provider’s NPI – 2310B (Header)/2420A (Line), NM108 = “XX”

Rendering Provider’s NPI – 2310B (Header)/2420A (Line), NM109

2.7. Rendering Providers

Rendering providers must be reported on professional services. There is a new requirement for

rendering providers that they must also be reported on laboratory, radiology, injections, supplies, items,

and all other services reported on a CMS 1500 format claim.

Even though one may think of a lab code, a radiology code, or other service codes on the claim as not

being performed by the physician or physician extender, but rather by a lab or radiology technician, or

an injection or other treatment as being performed by a nurse or other staff, the provider overseeing

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

12 | P a g e

the primary service for the recipient is still to be reported as the rendering provider for these types of

services.

Rendering providers may either be reported at the header level (if a single provider is the rendering

provider) or at the line level.

In many hospitals, the rendering provider may be a resident, an intern, or a supervised nurse,

technician, or other individual not typically enrolled as a provider in their own right. In these situations,

the supervising provider may be considered the rendering provider and reported as such.

Referring or ordering providers are to be reported when the service is a result of a referral or an order. It

may also be reported at the header level on a claim or at the line lever.

Specific Provider Reporting Requirements

Multidisciplinary Team Services

MAD is still working on issues with BH Agencies, Certified Mental Health (MH) Centers, BH Core Service

Agencies, Opioid Treatment Centers, Health Homes, and Case Management Agencies, regarding

reporting rendering providers on any service which is rendered by a multidisciplinary team. For these

providers, for services that are not provided by a multidisciplinary team, the provider must report

rendering providers and proceed with enrolling all practitioners on their staffs.

If the rendering provider is a resident, intern, supervised nurse, technician, or other qualified individual

who cannot enroll as a provider in their own right, the supervising provider may be considered the

rendering provider and reported as such.

Referring and Ordering Providers:

In addition to a rendering provider, the referring or ordering provider may also be reported. For the

Medicaid program, MAD does not distinguish between an ordering and referring provide and the

information may be placed in either the ordering or referring provider fields. These instructions are for

using the referring provider fields.

If the referring, ordering, or prescribing provider is a resident, an intern, a supervised nurse, technician,

or other qualified individual who cannot enroll as a provider in their own right, the supervising provider

may be considered the rendering provider and reported as such.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

13 | P a g e

Correct Placement of Information

Rendering Physician or Other Provider - Report on all Professional Services

Paper CMS 1500: Report the NPI of the rendering provider in Field Locator 24 J lower line

Rendering Provider ID number.

Electronic 837P: The following loop, segment, and element places are used to

report the rendering provider’s NPI and name, depending on whether

reporting is being done at the header or line level.

Rendering Provider – 2310B (Header)/2420A (Line), Data Element NM101 = “82”

Rendering Provider Last Name 2310B (Header)/2420A (Line), Data Element NM103

Rendering Provider First Name – 2310B (Header)/2420A (Line), NM104

Rendering Provider’s NPI – 2310B (Header)/2420A (Line), NM108 = “XX”

Rendering Provider’s NPI – 2310B (Header)/2420A (Line), NM109

Rendering Dentist or Other Provider, Report on Dental Services

Paper ADA form: Report the NPI of the rendering provider in Block 54.

Electronic 837D: The following loop, segment and element places are used to report the

rendering provider’s NPI and name, depending on whether reporting is

being done at the header or line level.

Rendering Provider – 2310B (Header)/2420A (Line), Data Element NM101 = “82”

Rendering Provider Last Name - 2310B (Header)/2420A (Line), Data Element NM103

Rendering Provider First Name – 2310B (Header)/2420A (Line), NM104

Rendering Provider’s NPI – 2310B (Header)/2420A (Line), NM108 = “XX”

Rendering Provider’s NPI – 2310B (Header)/2420A (Line), NM109

Referring or Ordering Physicians or Other Provider) - Reported When Applicable

Paper CMS 1500 format: Report the NPI of the referring or ordering provider in Field Locator 17b

(Other Physician’s Name and Identifier).

Electronic 837P: The following loop, segment and element places are used to report the

referring provider’s NPI and name, depending on whether reporting is

being done at the header or line level.

Referring Provider – 2310A (Header)/2420F (Line), Data Element NM101 = “DN”

Referring Provider Last Name – 2310A (Header)/2420F (Line), Data Element NM103

Referring Provider First Name – 2310A (Header)/2420F (Line), NM104

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

14 | P a g e

Referring Provider’s NPI – 2310A (Header)/2420F (Line), NM108 = “XX”

Referring Provider’s NPI – 2310A (Header)/2420F (Line), NM109

Referring or Ordering Dentist On Dental Claims - Reported When Applicable

Paper ADA: Form does not have this field. Cannot be reported.

Electronic 837: The following loop, segment and element places are used to report the

referring provider’s NPI and name, depending on whether reporting is

being done at the header or line level.

Referring Provider – 2310A (Header)/2420F (Line), Data Element NM101 = “DN”

Referring Provider Last Name – 2310A (Header)/2420F (Line), Data Element NM103

Referring Provider First Name – 2310A (Header)/2420F (Line), NM104

Referring Provider’s NPI – 2310A (Header)/2420F (Line), NM108 = “XX”

Referring Provider’s NPI – 2310A (Header)/2420F (Line), NM109

2.8. Using the Web to Verify Attending, Ordering, Referring, Rendering or Prescribing Providers

It is ultimately the responsibility of the Medicaid provider billing the service to obtain the NPI of the

prescribing, referring, ordering, attending, or rendering provider and to confirm the provider’s active

enrollment in the Medicaid program. Each Medicaid provider will need to develop its own internal

processes to ensure the enrollment requirement is met or the provider risks the claim being denied.

A provider may look up the NPI of a provider participating in the Medicaid program on the Conduent

New Mexico Medicaid web portal and may also determine if the attending, ordering, referring,

rendering, or prescribing provider is enrolled in the Medicaid FFS or managed care program as required.

From the main ‘Provider Information’ section of the portal

https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm

Click on the ‘Provider Search’ link on the left side of the screen (highlighted in yellow below.) It can

also be accessed directly by going to the URL:

https://nmmedicaid.portal.conduent.com/webportal/providerSearch

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

15 | P a g e

3. Then search by NPI, organization name, or provider name.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

16 | P a g e

4. You will get results such as those below.

5. To be considered to meet the Medicaid FFS or managed care enrollment requirements, a provider

must either be “active” as a status 60 or “MCO” as a status 70 on the date of service on the claim.

6. If you do not get any results, re-check the information entered.

7. If you do not find the ordering, referring, or prescribing provider listed, and the individual provider

works for the Indian Health Services or a tribal health care facility, an FQHC, or is a resident at

University of New Mexico Hospital (UNMH), you can look up the organization using the provider

name search field and use the NPI of that entity on the claim.

You can search for an organization by putting part of the organization’s name in the search field. The

NPI of an organization such as those listed above may be entered as the prescriber or referring

provider.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

17 | P a g e

2.9. Exclusions

At this time, reporting the rendering, referring, ordering, or attending providers on a claim are not

required for the following provider types. However, to the extent that an MCO may already be requiring

such information, there is no need for the MCO to discontinue the requirement.

Provider Type

Description

221

Indian Health Services Hospital or Tribal Compact facility –

specialty required, multiple specialties allowed

313

Clinic FQHC, Medical

314

Clinic, Rural Health Medical, freestanding

315

Clinic, Rural Health Medical, hospital-based

343

Methadone Clinic

346

Lodging, Meals

363

Community Benefit Provider (enrolled for MCOs only)

401

Ambulance, Air

402

Ambulance, Ground

403

Handivan

404

Taxi, or MCO General Transportation Contractor (Non-Capitated)

462

Case Management Agency (specialty required)

This may change in the future as we work with CMS and providers.

HSD is not addressing value-added services (VAS) at this time. If an MCO feels it is appropriate to notify

providers of VAS that a rendering or referring provider or ordering provider is required, an MCO may do

so. For example, a physician applying a dental fluoride varnish would reasonably be expected to be

identified as a rendering provider; however, this is not stated on any FFS list.

When Medicare or a Medicare Advantage program has paid the claim, and the claim is being evaluated

for co-insurance, deductible or co-payment, rendering, referring, ordering, or attending providers on a

claim are not required. However, for any other claim with a prior payment, such as from an insurance

company or a health maintenance organization plan, there is no exemption. The provider must add the

information to the claim.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

18 | P a g e

If MAD does not enroll certain providers of services that are in managed care, such as Support Brokers,

there is no requirement for them to be actively enrolled in Medicaid. If a provider is enrolled or

identified with a provider type in the 900 series of provider types, which are only applicable to managed

care (such as a traditional healer), there is no current requirement that rendering, referring, ordering,

attending providers be reported.

Medicaid is not requiring changes for pharmacy claims at this time. MAD is working on system changes

within the State system to meet the Federal requirements for prescriber, but more work is needed.

MCOs do not need to remove any requirements on pharmacy claims they may already have in place.

School-based health clinics are not exempt from the requirements. Neither are out of state,

out-of-network providers, or single case agreement providers exempt from the rule.

2.10. General Information on the Requirements based on Procedure Codes

Each procedure code in the Omnicaid System has an indicator on it that indicates if a rendering provider

is required (with an S), a referring provider is required (with an R), or whether both are required (with a

B) or if nothing is required (with an N).

A list of codes with the indicators is periodically provided to each MCO which includes most codes on

the Rendering Provider Required by Procedure Code List.

However, there are some important considerations in using that list:

1. Referring Requirements for Laboratories, Radiology Facilities, Suppliers of Prosthetics and

Orthotics, Oxygen, DME, and Medical Supplies

The indicator on the procedure code list is not applicable to services billed by laboratories, radiology

facilities, prosthesis and orthosis suppliers, oxygen suppliers, durable medical equipment and

medical supply suppliers.

For these providers there is always an expectation that the services were ordered and therefore the

ordering provider must be indicated.

Therefore, for example, the indicator on a lab code that says a rendering provider is required does

not apply to these providers, not even the free-standing laboratory. Rather, the requirement that

there should always be a referring provider is applicable.

For a laboratory or radiology facility, a rendering provider would only be required when a

professional interpretation billed (typically using modifier 26).

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

19 | P a g e

For claim processing and encounter purposes MAD does not make a distinction between referring or

ordering providers. Either will meet the requirements when a referring provider is required.

2. Rendering Provider Requirements

The Rendering Provider Required by Procedure Code List described above may be used to determine

when a rendering provider is required. However, there are other aspects to be considered, such as

the billing provider type.

The following provider types are always exempt from reporting a rendering provider. This may

change in the future, but until individuals working within these providers are always enrolled, we

cannot enforce a rendering provider requirements:

Provider Type

Description

218

Treatment Foster Care Services

221

Indian Health Services Hospital or Tribal Compact facility

324

Nursing, Private Duty

334

Optician

336

Orthotist

337

Prosthetist

338

Prosthetist & Orthotist

343

Methadone Clinic

344

HCBS or Mi Via Self-Directed Waivers

346

Lodging, Meals

363

Community Benefit Provider

405

Birthing Centers

412

Hearing Aid Supplier

414

Medical Supply Company

415

IV Infusion Services

416

Pharmacy

417

Pharmacy, Rural Health Clinic (RHC)

441

Developmental Delay Services

447

Renal Dialysis Facility

462

Case Management Agency

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

20 | P a g e

For clarity, MAD has prepared a list of all FFS provider types for which a rendering provider may be

required (Rendering Provider Required by Provider Type List). If the provider is on this list, and the

procedure code is on the Rendering Provider Required by Procedure Code List, a rendering provider

should be reported.

The rendering provider cannot be the same as the billing provider if the billing provider is a group.

• A billing group provider number cannot be used as the rendering provider on the claim. There may

be various ways of enforcing this.

However, MAD has always designated whether a provider is a group practice or an individual. Most

individual health professionals can belong to a group practice or practice individually. When it is

possible for a provider ID to be either a “group” (G) or an “individual” (I), MAD is careful when

processing an application to designate the provider as either G or I.

This information is used when validating a rendering provider entered on a claim. Assume there is a

professional group such as Scrooge and Marley Pediatricians with a G indicator and there is an

individual within the group “Dr. Jacob Marley” with an I indicator.

If the billing provider Scrooge and Marley Pediatricians also enters their group NPI number in the

rendering provider field, the Medicaid Management Information Systems (MMIS) will detect the

rendering provider is the same as the billing group and deny the claim.

If the billing provider is an individual, Dr. Bob Cratchit, for example, and the NPI appears as both the

billing provider and the rendering provider, the MMIS will recognize that the billing provider is an

individual and therefore may certainly use the individual NPI in the rendering provider field. (This is

done by using by-pass logic in the edit.)

In the MMIS, the billing provider is propagated to the lines of the claim.

• This principle remains exactly the same for dental individual providers and dental group practices.

Not all providers can be designated as a G and having many employees does not make a provider a

group. The G distinction is largely for professional providers and the groups they form. Institutional

providers such as hospitals are considered I, not as group, as is a hospice or an HHA – that is, they

only function as individual entities.

The only exception is the FQHC because it is a clinic and a clinic is considered a group practice.

Depending on how the MCO processes Comprehensive Outpatient Rehabilitation Facility claims,

such as if they use the UB format, there is a requirement for rendering providers to be identified for

them.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

21 | P a g e

• One of the major new requirements for Medicaid is the rendering provider must be reported for

outpatient hospital services billed on the outpatient hospital claim.

• Behavioral Health Codes Exempted from Reporting Rendering Provider

It is anticipated that many of the BH codes listed below will, at some point, require a rendering

provider. Until there has been further communications with the providers, MAD will not require a

rendering provider for the following. A chart showing the rendering provider requirements for BH

services will be periodically updated and sent to the MCOs.

Note that for clarity, MAD will periodically send the MCOs lists of all codes that do and do not require a

rendering provider. Also, a transportation provider never has to identify a rendering provider.

Note that if a MCO is already requiring rendering providers for these codes, there is no need for a MCO

to stop doing so.

Also, please do not use this list to try to determine which codes are a benefit of the program. That is a

different issue. We do not necessarily cover all the codes described above.

3. Attending Provider Requirements by Provider Type

The following providers require an attending provider. A rendering provider is never required unless

the provider is not the facility, but rather a practitioner billing on the CMS 1500 form such as for

skilled nursing facility (SNF) rehabilitation services, for example.

Provider Type

Description

201

Hospital, General Acute Inpatient

202

Hospital, Rehabilitation Unit in a General Acute Hospital Inpatient

203

Hospital, Rehabilitation or Other Specialty Hospitals- such as LTAC hospitals - Inpatient

204

Hospital, Psychiatric Unit in a General Acute Hospital Inpatient

205

Hospital, Psychiatric Free-Standing Inpatient

211

NF, Private for NF Stays

212

NF, State for NF Stays

213

Hospital, Swing-Bed for NF Stays

216

ARTC, Joint Commission accredited for Residential Facility Stays

217

RTC, not Joint Commission accredited for Residential Facility Stays

219

RTC Group Home, not Joint Commission accredited for Residential Facility Stays

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

22 | P a g e

The attending provider cannot be the same as the billing provider and must be an individual

provider. The MMIS has edits that enforce this requirement.

4. The Referring Provider by Provider Type

The requirements for referring providers on some claims is covered in number 1, above. A referring

provider is required from the following unless otherwise exempted in this document (such as when

we say that Medicare cross overs are exempt from the requirement).

Provider Type

Description

351

Lab, Clinical Freestanding

352

Radiology Facility

353

Laboratory, Clinical with Radiology

354

Diagnostic Laboratory (physical measurements)

414

Medical Supply Company

415

IV Infusion Services

416

Pharmacy when billing on a CMS 1500 format

417

Pharmacy, RHC when billing on a CMS 1500 format

451

Occupational Therapy (OT) (may self-refer)

452

Occupational Therapist Licensed, not certified (may self-refer)

453

Physical Therapy (PT) (may self-refer)

454

Physical Therapist, Licensed, not certified (may self-refer)

Additional circumstances for which a referring provider is required are as follows:

Provider Type

Description

324

Nursing, Private Duty - referring is required when not being billed by an HHA

334

Optician - a referring provider must be indicated for glasses but not for repairs

Other providers are to report a referring provider when there is one, but generally unless the MCO

specifically requires a referring provider for a service, it is not known whether the service was due to

a referral.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

23 | P a g e

However, the following procedure codes would seem to logically have a referring provider so it must

be reported for them:

Description

Procedure Code

Requirement

Office Consultation

99241

R-Referring

Office Consultation

99242

R-Referring

Office Consultation

99243

R-Referring

Office Consultation

99244

R-Referring

Office Consultation

99245

R-Referring

At this time, CMS rules allow Medicaid to accept the referring provider can be an institution and not

necessarily an individual. This is generally allowed when the referring provider is with a type of

institution such as UNMH, an IHS facility, or tribal facility where interns, residents, and non-enrolled

staff might be practicing. MCOs must also allow for this.

2.11. Appendices

2.11.1 Notification of Change in Services – Notification of Transition

2.11.2 MCO Notification to HSD of Change or Closure- Narrative for Provider/Facility

2.11.3 Transition Plan A- Overall Transition Plan Information- MCO Transition Plan for Provider/Facility

2.11.4 Transition Plan B- Member Specific Information for Provider

2.11.5 Definitions

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

24 | P a g e

2.11.1. Notification of Change in Services – Notification of Transition

MCO NOTIFICATION TO HSD- NOTICE OF CHANGE IN SERVICES ☐

MCO NOTIFICATION TO HSD- NOTICE OF TRANSITION ☐

*Expected Change ☐ *Unexpected Change ☐

Date:

Date MCO Notified of Closure:

Anticipated Date of Closure:

Name of Provider or Facility:

Type of Provider Individual:

☐Group:

☐Agency: ☐

Facility: ☐

Full contract termination? Yes ☐ No ☐

Addresses of all locations (include county and region type):

Type(s) of Service(s):

Satellite location terminating? Yes ☐ No ☐

Address of location terming (include county and region type):

Type(s) of Service(s) at location:

Terminating Services only? Yes ☐ No ☐

Type(s) of Service(s):

Total Number of Members Affected: <21 >21

Transition Plans Required? Yes ☐ No ☐

Narrative Due Date: (Due 10 calendar days after Notification):

The below items should be filled in only if transition plans are required.

Transition Plans A & B Due Date:

(Due 15 calendar days after Notification)

Name of MCO Staff and/or Care Coordinator Responsible for Transition:

*Notification of unexpected change is due within five business days of confirmed change. Notification of expected change is due

30 days prior to the confirmed change.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

25 | P a g e

2.11.2. Transition Plans Narrative

MCO Notification to HSD of Change or Closure

Narrative For

(Provider/Facility Name)

Date:

MCO Staff and/or Care Coordinator:

Describe the reason(s) and/or circumstances and any contributing factors to the change or closure:

How the change affects delivery of, or access to, covered services (describe how the change impacts the

system as whole and at the community level):

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

26 | P a g e

The MCO’s plan for maintaining access and the quality of Member care:

Please explain all factors considered in making the determination that the change will not significantly

impact the system and provide assurances that all Members will be transitioned to new providers (if

applicable).

Transition issues identified

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

27 | P a g e

2.11.3. Transition Plan A

Overall Transition Plan Information

MCO Transition Plan For

(Provider Name) (Date)

MCO task

assignment

Comments

Begin

Date

End Date

1. Preplanning

MCO receives communication of

contract, location, service closure.

Closing program sends a formal

letter to MCO advising of closing.

List of affected members sent to

MCO.

List of special problems expected or

associated with transition.

MCO letter to affected members

offering assistance (as needed).

2. Network Operations

Contracting department to complete

Table A Provider Information.

3. Transition planning

Meeting with program or director.

Complete plan to ensure program is

appropriately referring and

transitioning affected members.

Progress updates of transition

program.

Template for Records Retention

Completed and attached.

4. Communication to HSD

Submit notification.

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

28 | P a g e

MCO task

assignment

Comments

Begin

Date

End Date

Submit narrative.

Submit Transition Plan A.

Submit Transition Plan B.

Bi-weekly updates of transition plans

and narrative from MCO to state

agency contact person.

5. Care Coordination

Identify Care Coordinators to be

contact point for members seeking

assistance.

Care Coordinator review of

community resources.

Care coordination and MCO

Clinical/UM Department tasks.

Compile weekly report of care

coordination.

Meeting with MCO and program

transition team to coordinate efforts,

if applicable.

Other requirements as needed

depending on circumstances of

closing.

Transition plan finalized.

MCO certifies the transition of all members has taken place and is finalized.

Signature:

Date: __________________

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

29 | P a g e

2.11.4. Transition Plan B

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

30 | P a g e

Section 2: Provider Network

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

31 | P a g e

2.11.5. Definitions

• Certified Nurse Midwife (CNM) means a registered nurse pursuant to the Nursing Practice Act who

is licensed by the board of nursing for advanced practice and licensed by the Department of Health

as a nurse-midwife.

• Certified Nurse Practitioner (CNP) means a registered nurse who is licensed by the

board for advanced practice as a certified nurse practitioner and whose name and

pertinent information are entered on the list of certified nurse practitioners maintained by

the board.

• Clinical Nurse Specialist (CNS) means a registered nurse who is licensed by the board

for advanced practice as a clinical nurse specialist and whose name and pertinent

information are entered on the list of clinical nurse specialists maintained by the board.

Section 3: Member Education

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

32 | P a g e

3. Member Education

3.1. Policies and Procedures

The MCO shall maintain policies and procedures governing the development and distribution of

educational material for members. Policies shall address how members and potential members receive

information, the means of dissemination and the content comprehension level, and languages of this

information. The MCO shall have written policies and procedures regarding the utilization of information

on race, ethnicity, and primary language spoken by its membership.

All written member materials shall meet the material guidelines established in the Agreement and

defined in Section 11 Marketing of this Manual. All materials distributed shall include a language block

informing the member that the document contains important information and directs the member to

call the MCO to request the document in an alternative language or to have it orally translated at no

expense to the member. The language block shall be printed, at a minimum, in the non-English

languages meeting the requirement of Subsection A of 8.308.8.10 NMAC.

MCOs shall provide members the option of receiving materials via mail, email, or website in accordance

with 42 CFR 438.10. Member materials and enrollee information may not be provided electronically to

the enrollee unless all of the following are met:

• The information is provided electronically after obtaining the enrollee’s consent to receive the

information electronically;

• The format is readily accessible;

• The information is placed in a location on the MCO’s website that is prominent and readily accessible;

• The information is provided in an electronic form that can be electronically retained and printed;

• The information is consistent with the content and language requirements of Section 42 CFR 438.10;

and

• The enrollee is informed the information is available in paper form without charge upon request and

the MCO provides it upon request within 5 business days.

The MCO shall provide written notice to members of any material changes previously sent at least 30

calendar days before effective date of the change.

Section 3: Member Education

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

33 | P a g e

3.2. Member Handbook

The MCO member handbook must include a table of contents and, at a minimum, comply with the

following:

• MCO demographic information, including the organization’s hotline telephone number and hours of

operation;

• Information on how to obtain services such as after-hours and emergency services, including the

911 telephone system or its local equivalent, and Nurse Advice line;

• Member bill of rights and member responsibilities, including any restrictions on the member’s

freedom of choice among network providers;

• Information pertaining to coordination of care by and with PCPs (within the MCO), as well as

information pertaining to transition of care (between the MCOs);

• How to obtain care in emergency and urgent conditions and that prior authorization is not required

for emergency services;

• The amount, duration, and scope of mandatory benefits;

• Information on accessing BH or other specialty services, including a discussion of the member’s

rights to self-refer to in-plan and out-of-plan family planning providers, a female member’s right to

self-refer to a women’s health specialist within the network for covered care, and that members

may self-refer for BH services and are not required to visit their PCP first;

• Limitations to the receipt of care from out-of-network providers;

• A list of services for which prior authorization or a referral is required and the method of obtaining

both;

• Information on Utilization Management (UM) Services;

• A policy on referrals for specialty care and other benefits not furnished by the member’s PCP;

• Information on how to obtain pharmacy services;

• Information regarding Grievances, Appeals, and Fair Hearing procedures and timeframes including

all pertinent information provided in 42 CFR 438.00 through 438.424;

• Information on the member’s right to terminate enrollment and the process for voluntarily

dis-enrolling from the plan;

• Information on the MCO switch process;

• Information on how members change their demographic information.

Section 3: Member Education

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

34 | P a g e

• Information regarding advance directives including advance directives for BH;

• Information regarding how to obtain a second opinion;

• Information on cost sharing, if any;

• How to obtain information, upon request, determined by HSD as essential during the member’s

initial contact with the MCO, which may include a request for information (RFI) regarding the MCO’s

structure, operation, and physician’s or senior staff’s incentive plans;

• Value-added benefits which are not covered by the Agreement and how the member may access

those benefits;

• Information regarding the birthing option program;

• Language that clearly explains that a Native American member may self-refer to an IHS or a tribal

health care facility for services;

• Information on how to report fraud, waste and abuse;

• Information on member’s privacy rights;

• Information on the circumstance/situations under which a member may be billed for services or

assessed charges or fees; specifically that the provider may not bill a member or assess charges or

fees except: if a Member self-refers to a specialist or other provider within the network without

following contractor procedures (e.g., without obtaining prior authorization) and the contractor

denies payment to the provider, the provider may bill the member, if a provider fails to follow the

contractor’s procedures, which results in non-payment, the provider may not bill the member, and if

a provider bills the member for non-covered services or for self-referrals, he or she shall inform the

member and obtain prior agreement from the member regarding the cost of the procedure and the

payment terms at time of service;

• Information on how to access services when out of state;

• Include information about Care Coordination, including the role of Care Coordinators; and

• Information on the centennial rewards program and how a member accesses the program and earns

rewards.

Section 3: Member Education

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

35 | P a g e

3.3. Provider Directories

The MCO may choose to maintain regionalized, printed, or printable provider directories by Northern,

Southern, and Central regions of the State; however, each regionalized provider directory must include

telephone numbers for crisis lines, Member Services line, all out of state providers and Bernalillo

County providers. Information on how to access these regionalized provider directories online or how

to request a copy should be indicated on the MCO’s website and in the Member Handbook.

Online provider directories must be comprehensive and inclusive of all providers in all regions, as well as

telephone numbers for crisis lines, Member Services line, and all out of state providers.

3.4. Member Identification Card

The member ID card shall be durable (e.g., plastic or other durable paper stock but not regular paper

stock), shall comply with all State and Federal requirements and, at a minimum, shall include:

• The MCO’s name and issuer identifier, with the company logo;

• Phone numbers for information and/or authorizations, including for physical health (PH), BH, and

Long-Term Care (LTC) services;

• Descriptions of procedures to be followed for emergency or special services;

• The member’s identification number;

• The member’s name (first, last, and middle initial);

• The member’s date of birth;

• The member’s enrollment effective date;

• The member’s PCP;

• Whether the member is enrolled in the Alternative Benefit Plan;

• The member’s State-issued Medicaid identification number. This number is the ten-digit number

supplied to the MCO in the nightly batch of member information sent from HSD; and

• All applicable co-payment amounts.

3.5. Member Advisory Board

The MCO shall convene and facilitate a Member Advisory Board and adhere to all requirements below.

Member Advisory Board members shall serve to advise the MCO on issues concerning service delivery

and quality of all Covered Services (e.g., BH, PH and LTC), Member rights and responsibilities, resolution

Section 3: Member Education

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

36 | P a g e

of Member Grievances and Appeals and the needs of groups represented by Member Advisory Board

members as they pertain to Medicaid.

The Member Advisory Board shall consist of members (with representation of all Medicaid populations

enrolled in the MCO), family members, and providers. The MCO shall have an equitable representation

of its members in terms of race, gender, special populations, and New Mexico’s geographic areas.

The MCO’s Member Advisory Board shall keep a written record of all attempts to invite and include its

members in its meetings. The Member Advisory Board roster and minutes shall be made available to

HSD 10 calendar days following the meeting date.

The MCO shall hold quarterly, centrally-located Member Advisory Board meetings throughout the term

of the Agreement. The MCO shall advise HSD 10 calendar days in advance of meetings to be held.

In addition to the quarterly meetings, the MCO shall hold at least two additional statewide Member

Advisory Board meetings each contract year that focus on member issues to ensure members’ issues

and concerns are heard and addressed. Attendance rosters and minutes for these two statewide

meetings shall be made available to HSD within 10 calendar days following the meeting date.

The MCO shall ensure all Member Advisory Board members actively participate in deliberations and that

no one Board member dominates proceedings in order to foster an inclusive meeting environment.

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

37 | P a g e

4. Care Coordination

4.1. General Information

The MCO, through implementation of its policies and procedures, will develop a comprehensive program

for continuous monitoring of the effectiveness of its care coordination processes. The policies and

procedures will include the staff responsible for the monitoring, how the monitoring will be done, as

well as the frequency of the oversight. Care Coordination strategies will be analyzed for effectiveness

and appropriate changes made. Any issues or concerns will be addressed immediately.

4.2. Care Coordination Functions

The following primary care coordination functions are requirements for care coordination that must be

performed by staff employed by the MCO.

• Conducting Health Risk Assessments (HRAs) for members newly enrolled in Centennial Care or

members who have had a change in condition and who are not currently identified for Care

Coordination Level 2 or 3 services;

• Conducting Comprehensive Needs Assessments (CNAs) initially, semi-annually or annually;

• Administer the Community Benefit Service Questionnaire (CBSQ) as applicable (see Section

4.5 CBSQ);

• Semi-annual or quarterly in-person visits with the member;

• Quarterly or monthly telephone contact with the member;

• Comprehensive Care Plan (CCP) development and updates; and

• Targeted Health Education, including disease management, based on the member’s individual

diagnosis (as determined by the CNA).

MCOs may delegate care coordination functions in the following instances:

• MCOs that own and operate patient-centered medical homes (PCMHs) as part of their provider

network may delegate to such PCMHs, provided the PCMH Care Coordinator is employed by the

MCO;

• MCOs may delegate all primary care coordination functions to a designated Section 2703 Health

Home, provided the Health Home is determined ready by the Health Home Steering Committee to

perform such functions;

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

38 | P a g e

• MCOs may fully delegate care coordination to providers/health systems in a value-based purchasing

(VBP) arrangement that outlines a payment arrangement for the full delegation of Care

Coordination and other requirements associated with improving quality and health outcomes;

and/or

• MCOs may delegate the HRA, CNA, care coordination touch points with high need members,

coordination of referrals, linking Members to community services, and locating and engaging with

Unreachable and Difficult to Engage Members as part of the Shared Function Model with entities or

individuals for a mutually-agreed upon reimbursement rate.

The MCOs may not delegate the NF level of care (LOC) assessment and may not delegate care

coordination for members who are in the SDCB model.

The MCO, through its care coordination monitoring of MCO staff and care coordination delegates, will

ensure, at a minimum:

• The care coordination tools and protocols are consistently and objectively applied and outcomes are

continuously measured (frequency and methodology stated in the policies and procedures such as

inter-rater reliability) to determine effectiveness and appropriateness of processes.

• Competencies will be evaluated in the following areas, but not limited to:

o LOC assessments and reassessments occur on schedule in compliance with the Agreement and

are submitted to the lead or supervising Care Coordinator;

o CNAs and reassessments, as applicable, occur on schedule in compliance with the contract;

o Care plans are developed and updated on schedule in compliance with the Agreement;

o Care plans reflect needs identified in the CNA and reassessment process;

o Care plan goals are member-centric, and agreed-upon by the member;

o Care plans are appropriate and adequate to address the member’s needs including the need for

all Community Benefit (CB) services;

o Services are delivered as described in the care plan and authorized by the MCO;

o Services are appropriate to address the member’s needs; including culturally responsive

treatments and supports to Native American children and youth in CYFD Protective Services (PS)

custody;

o Services are delivered;

o Service utilization is appropriate;

o Service gaps are identified and addressed;

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

39 | P a g e

o Minimum Care Coordinator contacts are conducted;

o Care Coordinator-to-member ratios are appropriate;

o Service limits are monitored (as described in the policies and procedures) and appropriate

action is taken if a member is nearing or exceeds a service limit; and

o CBSQ is administered as appropriate.

• The MCO, or its delegate, will use an electronic case management system that includes the

functionality to ensure compliance with all requirements specified in the 1115(a) Waiver, Federal

and State statutes, regulations, the Agreement and the MCO’s policies and procedures. The

functionality will include but not be limited to the ability to:

o Capture and track enrollment dates, date of development of the care plan, date of authorization

of the care plan, date of initial service delivery for each service in the care plan, date of each LOC

and needs reassessment, date of each update to the care plan, and dates regarding transition

from an institutional facility to the community;

o Capture care coordination level assignments and track compliance with minimum care

coordination contacts as specified in the Agreement;

o Notify the Care Coordinator of eligibility end date, date for annual LOC reassessment, date of

comprehensive needs reassessment, and date to update the care plan;

o Capture and track eligibility/enrollment information, LOC assessments and reassessments, and

needs assessments and reassessments;

o Capture and monitor the care plan;

o Track requested and approved service authorizations, including Covered Services and VAS, as

applicable;

o Document all referrals received by the Care Coordinator on behalf of the member for Covered

Services and VAS, as applicable, needed in order to ensure the member’s health, safety and

welfare, and to delay or prevent the need for more expensive institutional placement. Include

notes regarding how such a referral was handled by the Care Coordinator, including any

additional follow up;

o Establish a schedule of services for each member identifying the time that each service is

needed and the amount, frequency, duration and scope of each service;

o Track service delivery against authorized services and providers;

o Track actions taken by the Care Coordinator to immediately address service gaps;

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

40 | P a g e

o Document case notes relevant to the provision of care coordination; and

o Allow HSD or its designee to have remote access to case files.

4.3. Health Risk Assessment

The MCO or its delegate shall conduct HSD standardized HRAs on all members who are newly enrolled in

Centennial Care for the purpose of: introducing the MCO to the member, obtaining basic health and

demographic information about the member, and confirming the need for a CNA to determine if the

member should be assigned to care coordination level 2 or level 3. The MCO may assign a member for

care coordination without completion of a CNA, provided they obtain HSD approval in advance of the

level assignment.

The standardized HRA (Section 4.15.1.) will be completed for each new Centennial Care member within

30 calendar days of the member’s enrollment in the MCO. Additionally, an HRA will be completed upon

a change in the member’s health condition if the member is not in care coordination level 2 or level 3.

The HRA may be conducted by telephone, in person, or as otherwise approved by HSD; HRA information

must be obtained from the member or the AR and must be documented in the member’s file. The MCO

shall ensure its staff, subcontractors, or vendor(s) conducting the HRA are adequately trained to

effectively conduct the HSD standardized HRA.

The MCO or its delegate will make reasonable efforts to contact members to conduct an HRA and

provide information about care coordination. Such efforts shall include, but not be limited to, engaging

community supports such as Community Health Workers (CHWs), Community Health Representatives

(CHRs), Core Service Agencies (CSAs), 1915 (c) HCBS Waiver Case Managers and Consultants, New

Mexico Brain Injury Resource Center, and Centers for Independent Living. For CYFD protective services

(PS) and/or juvenile justice services (JJS) involved children/youth, the MCO or its delegate will

collaborate with the assigned CYFD permanency placement worker (PPW), juvenile probation officer

(JPO), and community behavioral health clinician (CBHC) for physical and behavioral health services. The

MCO or its delegate shall document at least three attempts to contact a member which includes at least

one attempt to contact the member at the most recently reported phone number. The three attempts

shall be followed by a letter sent to the member's most recently reported address that provides

information about care coordination and how to obtain an HRA. Documentation of the three attempts

shall be included in the member’s file. Such attempts shall occur on not less than three different

calendar days, at different hours of the day, including day and evening hours and after business hours.

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

41 | P a g e

After these attempts have been made and documented, and if the member has not been engaged, the

member is categorized as “Unreachable” and is not assigned to care coordination level 2 or level 3. The

MCO will conduct quarterly claims mining for these members and will renew attempts to reach the

member if claims indicate a possible need for care coordination.

If the MCO has made three documented attempts to contact and has reached the member at least once,

but the member fails to engage with the completion of the HRA or CNA, the member is categorized as

“Difficult to Engage” (DTE) and is not assigned a care coordination level 2 or level 3. If the member is

categorized as a care coordination level 2 or level 3 based on the most recent CNA but fails to engage in

two consecutive contract required touch points (telephonic or in person), the member is then

categorized as DTE, with appropriate documentation in the member’s file. The MCO will perform

quarterly claims mining for these Members and will renew attempts to reach Members if claims mining

indicates a possible need for care coordination.

The HSD standardized HRA includes the following information:

• Member demographics

o Member name, address, telephone number, date of birth;

o Member Medicaid number;

o Names and relationship of person(s) completing form (other than member);

o Emergency contact and telephone number;

o HRA date; and

o Assessment Method and Type.

• Member Health Information

o Language preference, translation needs, and special preferences (cultural, religious, physical);

o Main health concern;

o Current or past PH and BH conditions or diagnoses, including brain injury;

o Pending PH or BH procedures;

o Most recent physical examination and/or recent medical appointment;

o Emergency room visits, including reason, number of visits and dates of visit(s);

o Number of hospital stays in past 6 months, and any readmissions;

o Indication of a 1915(c) waiver LOC assessment;

o Number of medications;

o Living situation;

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

42 | P a g e

o Assistance with two or more activities of daily living (ADL) and type of need;

o Interest in and need for LTC services;

o Advance directives preference and interest in receiving information; and

o Interest in receiving care coordination.

The MCO or its delegate shall provide the following information to every member during his or her HRA:

• The purpose of care coordination;

• The care coordination levels (CCLs);

• Notification of the member’s right to request a higher CCL;

• For Native American members, the right to have a Native American Care Coordinator;

• Requirement for an in-person CNA for the purpose of providing services associated with CCL2 or

CCL3; and

• Specific next steps for the member.

Within seven calendar days of completion of the HRA, all members shall be informed of the need for a

CNA. MCOs may request to add additional questions to the HRA to meet the requirements of regulatory

and accrediting bodies by submitting the additional questions and the reason(s) for inclusion for State

approval. Requests must be sent for approval to HSD/MAD through the MCO’s Contract Manager to the

attention of the Quality Bureau Care Coordination Unit (CCU).

The HRA and the CNA may be performed concurrently.

4.4. Comprehensive Needs Assessment

A CNA is conducted for Medicaid members eligible for managed care who are identified through the

HRA as having significant health conditions and risk indicators signifying the potential need for CCL2 or

CCL3. The MCO shall schedule a CNA within 14 calendar days of completion of the HRA and complete

the CNA within 30 calendar days of completion of the HRA unless the member is in a model approved

for delegated care coordination functions with other State-approved guidelines.

Members who are identified as not needing a CNA shall be monitored by the MCO care coordination

unit quarterly through predictive modeling software and available utilization and claims data to

determine if the member had a change in health status and is in need of an HRA or CNA.

For members who reside in a NF, rather than conduct a CNA, the MCO shall ensure the Minimum Data

Set (MDS) is completed and collect supplemental information related to BH needs and the member's

interest in receiving CB services.

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

43 | P a g e

For members who have indicators that may warrant a NF LOC, the MCO Care Coordinator shall conduct

an in person, in home CNA at the member’s primary residence. The MCO shall use the New Mexico

Medicaid NF LOC Criteria and Instructions to determine NF LOC for members.

The CNA is the sole responsibility of the MCO Care Coordinator unless delegated to another entity via a

Shared or Full Delegation Model.

CNAs must be performed through the utilization of an assessment tool that has been approved by HSD

for assessing the member’s medical/PH, BH, LTC, and social needs. The assessment tool may include the

identification of targeted needs related to improving health, functional outcomes, or quality of life

outcomes (e.g., related to targeted health education, pharmacy management, or increasing and/or

maintaining functional abilities, including provision of covered services). Any changes to the assessment

tool must be approved by HSD 30 calendar days prior to use by the MCO or its delegate.

The CNA must be conducted in the member’s primary place of residence or facility for members

reintegrating back into the community. The MCO or its delegate will involve collateral respondents

when scheduling the CNA, including family members, caregivers, CHRs, CHWs, and/or other significant

social support individuals, with the consent of the member. For CYFD PS and/or JJS involved

children/youth, the MCO or its delegate will collaborate with the assigned CYFD permanency placement

worker (PPW), juvenile probation officer (JPO), and community behavioral health clinician (CBHC) for all

medically necessary services including behavioral health services. The MCO or its delegate must

evaluate the need for translation, including signing or communication boards when scheduling the CNA.

CNAs must be conducted face-to-face with the member and collateral parties in the home, unless an

exception has been granted by HSD. Home setting is defined as the primary residence for the member in

the community where there is an identifiable address, and the member is residing for an established

period of time for shelter, safety, physical assistance, recovery, legal requirements, or treatment

services.

The CNA may be conducted without requesting an exception from the State under the following

conditions:

• If the member is homeless, or in a transition home or youth shelter and the assessment can be

conducted in a private setting at a location, mutually agreeable to the member, such as a church

meal site program, community non-profit organization center, community MH agency, food bank

site, etc.;

• If the member is currently part of the jail-involved population preparing for release; or

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

44 | P a g e

• If the Member is in a Health Home or being served by a provider approved for a Full Care

Coordination Delegation Model.

Other requests for exceptions to the CNA face-to-face or in the member’s home setting requirements

must be made directly to HSD by the MCO using the following process:

• Complete the Centennial Care CNA Exception Request form (MAD 601);

• Alternate locations must be submitted to HSD for review and should be assessed for privacy to

ensure the member’s Protected Health Information (PHI) is not jeopardized;

• Send the completed MAD 601 by secure email to: HSD-QB-CCU-CNA@state.nm.us;

• HSD will review the request and respond to the specific MCO requestor within two business days;

• If an exception is approved, it shall only be valid for six months, or until the next CNA is needed,

whichever comes first; and

• Requests will not be reviewed or approved if submitted:

o Via unsecure email;

o To an email address other than HSD-QB-CCU-CNA@state.nm.us; and

o Via any format other than the MAD 601 Form.

All efforts must be made to negotiate with and educate the member about the importance of

participating in the completion of a CNA. The MCO or its delegate must provide documentation of

further negotiations with the member and/or legal representatives when refusal by the member is

articulated.

CNAs are considered to be best practice and valid when conducted in the home setting. The home

setting must be evaluated for health, welfare, and safety of the member. The CNA, when conducted

with the member in his/her home, includes determination of: any structural problems for member’s

mobility access; need for safety enhancements, such as smoke detectors, fire extinguishers, ramps,

guard rails, and bathroom equipment; fall prevention concerns such as throw rugs; doorway access for

wheelchairs; plumbing and electricity issues; nutritional concerns such as no food resources or

food/beverage items identified as being beyond expiration dates; and other structural damages such as

mold, broken windows, entry doors without locks, broken flooring. Additional areas of considerations

include assessing for rodent/pest infestation, fire hazards due to electrical wiring issues and

clutter/hoarding, as well as outdoor hazards due to overgrown weeds and undergrowth of yards/trees.

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

45 | P a g e

The practice of conducting in home CNAs further allows for observation of the existence of other parties

living in the home and possibly presenting support or risk to the member.

When a member, currently categorized as a CCL2 or a CCL3, refuses to participate with a CNA, the MCO

will make every effort to discuss the benefits of the needs assessment with the member, emphasizing

this assessment makes the determination of useful resources to meet the member’s needs, such as the

CB for personal care assistance, special home environment modifications and adaptive equipment. The

MCO will ensure the member signs the HSD-approved care coordination declination form and maintain

the signed form in the member’s file. If the member refuses to sign the care coordination declination

form, the MCO shall document such refusal in the member’s record. The MCO will perform quarterly

claims mining for these members and will renew attempts to reach the member if claims mining

indicates a possible need for care coordination. The member who has refused care coordination will not

be assigned to care coordination level 2 or level 3. In documented refusal circumstances, the MCO will

submit a proposal to the member outlining a basic care plan with minimum services outlined and

suspend any requests for increased services/personal care hours until a CNA and NF LOC is conducted

and completed.

At a minimum, the CNA shall:

• Assess PH and BH needs, including but not limited to: current diagnoses; history of significant PH

and BH events, including hospitalizations and emergency room visits; complete placement history

for children and youth in CYFD PS custody; medications; allergies; providers involved in member’s

care; DME; brief substance abuse screening questionnaire, as approved by HSD/BHSD and history;

family medical and BH (MH and substance use/abuse) history; cognitive capacities, (including

evaluation of alertness, orientation, history of head/brain injury); health-related lifestyle (smoking,

food intake/nutrition, sleep patterns, exercise, continence); and functional abilities, including ADLs

(mobility, grooming, bathing, eating, dressing, and medications) and instrumental activities of daily

living (IADLs)(i.e., money management, meal preparation, housekeeping/cleaning, emergency

awareness and preparedness, and grocery shopping).

• Assess LTC needs including but not limited to: environmental safety including items such as smoke

detectors; pests/infestation; trip and fall dangers; and adaptive needs such as ramps or other

mobility assistance. If the member is eligible for the CB, the MCO shall assess for all CB services.

• Include a risk assessment, using a tool and protocol approved by HSD, as applicable. A risk

agreement that shall be signed by the member or his/her representative that shall include:

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

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identified risks to the member; the consequences of such risks; strategies to mitigate the identified

risks; and the member’s decision regarding his/her acceptance of risk.

• Assess disease management needs, including: identification of disease state; need for targeted

intervention and education; and development of appropriate intervention strategies.

• Determine a social profile including, but not limited to: living arrangements; natural and social

support systems which are available to assist the member; Individualized Planning Meeting Plans for

children and youth in CYFD PS custody; demographics; transportation; employment; financial

resources and challenges (other insurance, food, utilities, housing expenses); Medicare services;

other community services being accessed, such as senior companion services, meals-on-wheels,

etc.; living environment (related to health and safety); Individualized Education Plan; and

Individualized Service Plans for Developmental Disabilities, Medically Fragile (MF), or Mi Via Waiver

Program recipients, (if applicable). A copy of the HCBS Waiver Prior Authorization or budget is not

required to be obtained by the Care Coordinator.

• Identify possible suicidal and/or homicidal thinking, planning/intent and lethality risk, history of

aggressive and/or violent behaviors, history of running away and wandering for both adults and

children.

• Identify cultural information, including language and translation needs and utilization of ceremonial

or natural healing techniques.

• Ask the member for a self-assessment regarding their viewpoint of their condition(s) and service

needs.

• In the event the member is a minor under the age of 18, or is a youth in CYFD PS custody, identify

the parent or legal guardian participating in and/or responding for the minor during assessment.

• For members on the DD, Mi Via, or MF Waivers (categories of eligibility [COEs] 095 and 096) and as

applicable to the member’s living arrangement, identify the parent, family member or legal guardian

participating in and/or responding for the member during the assessment.

• In the event the member is receiving the Alternative Benefit Plan (ABP) and meets the definition and

criteria of Medically Frail or is otherwise ABP Exempt, notify the member that he/she may be

exempt, explain the difference in benefits and facilitate his/her transition to the ABP Exempt benefit

package at the member’s choice.

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4.5. Community Benefit Service Questionnaire

As part of the CNA process, MCO Care Coordinators must administer the CBSQ. The CBSQ/CBMA will be

administered as part of the CNA, at the beginning of the CNA. The CBSQ assists the Care Coordinator in

discussing all available CB services with the member, and the Community Benefit Member Agreement

(CBMA) elicits the member’s participation in identifying risks. The CBMA is not used to document the

member’s refusal to complete a CBSQ.

The completed CBSQ and the CBMA are considered part of the member’s CNA. The MCOs must ensure

all Care Coordinators are trained in administering these documents. The MCOs must have a process in

place to monitor that CBSQs and CBMAs are completed correctly and in accordance with Section 4.5 of

the Managed Care Policy Manual.

The CBSQ/CBMA will be administered as part of the CNA, at the beginning of the CNA, for the following

members:

• Allocated members receiving their first CNA, including members who are in the process of

community reintegration from a NF and members who lost their full Medicaid Category of Eligibility

(COE) and are being allocated for continuity of care.

• Annually for members with a current NF LOC (see note about CCL3 members below).

• Full Medicaid members without a NF LOC who request CB services.

• Full Medicaid members without a NF LOC who have not requested CB services but appear to meet

NF LOC criteria prior to or during the CNA. MCOs must attempt to determine this through claims

data or other information obtained prior to the member’s CNA including the functional needs

identified in the HRA.

The CBSQ/CBMA will not be administered for the following members:

• Members who have not previously met a NF LOC and who are not requesting CB at the time of the

CNA.

• Members who may meet a NF LOC for a short period of time due to a clinical episode

(e.g., pregnancy).

• Members not being assessed for a NF LOC.

• Members on the DD, Mi Via, or MF Waivers (categories of eligibility [COEs] 095 and 096).

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• Members in a NF (unless in the process of being allocated through community reintegration or

member has a COE (i.e., Supplemental Security Income [SSI]) that deems them eligible to reintegrate

without a waiver allocation).

• Members who decline assessment for NF LOC or refuse CB services. The MCO Care Coordinator

must document the refusal in the member’s record.

• Members who decline care coordination. The declination form must be on file with the MCO. If a

member refuses to sign the care coordination declination form, the contractor shall document such

refusal in the member’s record.

CCL3 members:

• For all members with CCL3 and a NF LOC, the CBSQ/CBMA must be administered at least annually or

more frequently as determined by the Care Coordinator.

• For members with CCL3 but without a NF LOC, follow the criteria above.

In any circumstances not covered by the criteria, the Care Coordinator should use his/her judgment and

consult with his/her supervisor as necessary to determine appropriate use of the CBSQ. Care

Coordinators should use the CBSQ as a tool to guide the discussion with the member and/or the

member’s representative to inform them of the availability of CB services.

HSD will audit CBSQ and CBMA completion to ensure that these requirements are met.

4.6. CNA Reassessments

The CNA shall be conducted at least annually for level 2 care coordination and semi-annually for level 3

care coordination, to determine if the care plan is appropriate for the member and if a higher or lower

LOC coordination may be needed.

Additional CNAs may also be conducted, as the Care Coordinator deems necessary, as requested by the

member, provider, family member or legal representative, or as a result of a change in health status

and/or social support situation including changes in placement for children in CYFD PS custody.

Specific indicators warranting a need for conducting a new CNA may include but are not limited to:

significant changes in member’s medical and/or BH condition (decline or improvements in health

status); changes in setting of care (SOC), such as hospitalization, rehabilitation and/or short-term NF

admission (long-term NF stay(s) require administration of the MDS): residential treatment facility

admission; changes in the member’s family or natural/social support system (such as, sudden illness

and/or convalescence or death of a family caregiver); living arrangement disruption (loss of residence,

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eviction, fire/flooding, move to another family home); involvement of Adult Protective Services (APS),

Child Protective Services, Juvenile Justice Services, Behavioral Health Services and/or other New Mexico

Children, Youth & Family Department (CYFD) interventions; and changes in the amount of caregiver

services requested and requested amount exceeds the range of hours corresponding with member’s

existing assessment score. These events may at times not require a new CNA be completed. If a new

CNA is not conducted, the member’s record should clearly establish why the triggering event did not

result in the MCO conducting a new CNA. The decision can be made via telephone contact or face to

face visit with the member.

4.7. Comprehensive Care Plan Requirements

This policy is in conjunction with all elements described in the CCP Requirements outlined in the

Agreement, which defines the processes for development, implementation and management of a care

plan for all members in levels 2 and 3 of care coordination. The MCO- or HSD-approved designee is

responsible for ensuring a CCP is initiated upon enrollment and must oversee the Care Coordinator who

is responsible for coordinating all services in the CCP.

• CCP Scope and Process. The MCO- or HSD-approved designee must establish a process to ensure

coordination of care for members that includes:

o Coordination of the member’s PH, BH, and long-term health care needs through the

development of the CCP;

o Collaboration with the member, member’s friends and family (at member’s request), member’s

PCP, specialists, BH providers, other providers, communities, and interdisciplinary team experts

including the Individualized Planning Meeting Team for children and youth in CYFD PS custody,

as needed when developing the care plan, including documentation of all attempts to engage

providers and other individuals identified in the development of the care plan;

o With the member’s consent to share information, the care plan should be shared and utilized by

those involved in providing care to the member (e.g., BH providers should be aware and take

into consideration the member’s PH care issues when working with the member); and

o Verification of all decisions made regarding the member’s needs and services, and ensures all

information is documented in a written, CCP.

• CCP Development and Management:

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o The CCP is in a language the member and/or family member can understand. The member shall

lead the person-centered planning process to ensure the CCP is member-centric and agreed

upon by the member;

o The member may designate his/her representative to have a participatory role, as needed, and

as defined by the member, unless the representative has decision making authority, under law;

and

o The MCO or HSD approved designee shall develop the CCP within 14 business days of

completion of the CNA unless the member is in a health home and/or using the Treat First

model of care.

o The Care Coordinator shall:

▪ Ensure the member or member’s legal representative understands, reviews, signs and dates

the CCP.

▪ Provide a copy of the completed CCP to the member, member’s legal representative as

applicable or other providers authorized to deliver care to the member in a format that is

easily readable (e.g., 12 font).

▪ With the member’s and/or parent, legal guardian and/or CYFD worker's (if in CYFD Custody)

consent, confirm family, providers, or any other relevant parties are included in the

treatment and planning of the member’s CCP.

▪ Ensure timelines for the development and implementation and/or update the CCP are met.

▪ Facilitate treatment and coordinate with providers to assist the member and his or her

family and CYFD lead worker (if in CYFD custody) with navigating the system including

scheduling appointments, arranging transportation, or advocating for the member as

needed.

▪ Verify services have been initiated and/or continue to be provided as identified in the CCP

and ensure services continue to meet the member’s needs.

▪ With member’s consent, maintain appropriate, constant communication with community

and natural supports to monitor and support their ongoing participation in the member's

care.

▪ Identify, address, and evaluate service gaps to determine their cause and minimize any gaps

going forward and ensuring back-up plans are implemented and effectively working;

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including strategies for solving conflicts or disagreements, and provide clear

conflict-of-interest guidelines for all planning participants.

▪ Identify and list specific risk factors and changes to member’s risk, address those changes

and update the member’s risk agreement and CCP as necessary to include measures to

minimize the identified risks.

▪ Inform each member of his or her Medicaid eligibility status and end date and assist the

member with the process for eligibility redetermination.

▪ For children and youth in CYFD PS custody, inform Native American children and youth and

their permanency placement worker (PPW) of opportunities to receive culturally responsive

treatments, interventions and supports, including those that are non-medicalized.

▪ Educate members with identified disease management needs by providing specific disease

management interventions and strategies.

▪ Educate the member about his or her ability to have an Advance Directive and ensure the

member’s decision is well documented in the member’s file.

▪ Educate member about non-Medicaid services available as appropriate (e.g., Adult

Substance Abuse Residential Treatment, Detoxification, Home Delivered Meals, and Infant

MH).

▪ Reflect cultural considerations of the member and conduct the CCP process in a manner

that is accessible to individuals with disabilities and persons who are limited English

proficient.

o Required Elements of a CCP include the following:

▪ Pertinent member demographics and enrollment data.

▪ Ensure implementation of interventions and the dates by which the interventions must

occur and identify specific agencies or organizations with which treatment must be

coordinated, including non-Medicaid providers.

▪ Covered medical diagnosis, past treatment, previous or pending surgeries (as applicable),

medications and allergies.

▪ Member’s current status, including present levels of function in physical, BH cognitive,

social, and educational domains.

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▪ Member or family, foster family or extended kinship barriers to receiving treatment, such as

a member or family member’s inability to travel to an appointment or for children and

youth in CYFD PS custody who lack access to services in the child’s home community.

▪ Identify the member or family’s, foster family’s, and/or extended kinship/guardian’s

strengths, resources, priorities, and concerns related to achieving mutual recommendations

made in caring for the member.

▪ Services recommended achieve the identified objectives, including provider(s) or person(s)

responsible and timeframes for meeting the member’s desired outcomes.

▪ Identify services provided by natural supports that are scheduled to be enhancers and

back-up (including emergency purposes) to services that are authorized by the MCO.

▪ An interdisciplinary team, with member’s consent, including but not limited to: the Care

Coordinator; social worker; registered nurse (RN); medical director; PCP; and others must be

identified to develop, implement and update the CCP as needed and coordinate with the

Individualized Planning Team for each child or youth in CYFD PS custody.

▪ Reflect the setting in which the individual resides is chosen by the member, and is

integrated in and supports full access of members receiving HCBS, to the greater

community, including opportunities to seek employment and work in competitive

integrated settings, engage in community life, control personal resources, and receive

services in the community to the same degree of access as individuals not receiving

Medicaid HCBS.

▪ Reflect the member’s strengths and preferences.

▪ Identify goals and desired outcomes that reflect the least restrictive, community-based

services and supports (paid and unpaid) that will assist the member to achieve identified

goals, and include who will provide the services and supports.

▪ Identify goals and preferences related to relationships, community participation,

employment, income and savings, health care and wellness, education and others.

▪ Include services and, the purpose or control of which the member elects to self-direct.

▪ Prevent the provision of unnecessary or inappropriate services and supports.

o CCP Revisions

▪ The CCP will be revised when the member experiences one of the following circumstances:

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• Risk of significant harm: within one business day of the MCO receiving notification, the

care coordination team will convene, in person or by teleconference; and if necessary

the care plan will be modified accordingly within 72 hours;

• Major medical change;

• The loss of a primary caregiver or other significant person;

• A serious accident, illness, injury or hospitalization that disrupts the implementation of

the CCP;

• Serious or sudden change in behavior;

• Change in living situation, including out-of-home placements, removal from the home

by CYFD or changes in CYFD placements, and subsequent discharges;

• Proposed change in services or providers (e.g. CB);

• It has been confirmed by APS or CYFD that the member is a victim of abuse, neglect, or

exploitation;

• Any team member requests a meeting to propose changes to the CCP;

• Criminal justice involvement on the part of the member (e.g., arrest, incarceration,

release, probation, parole); or

• As requested by HSD.

▪ Within five business days of completing a reassessment of a member’s needs, the Care

Coordinator shall update the member’s CCP as appropriate, and the MCO or HSD approved

designee shall authorize and initiate services in the updated CCP.

o Ongoing Care Coordination

▪ This policy along with all elements described in Ongoing Care Coordination outlined in the

Agreement, defines how the MCO or HSD approved designee shall perform real time and

ongoing care coordination to ensure all members receive the appropriate care.

▪ Ongoing care coordination functions shall include all elements defined in the Agreement

including the following:

• Identify gaps and address the needs of the member, including develop and/or update

the care plan as needed.

• Ensure when a member’s LOC coordination increases or decreases that continuity of

care is always maintained.

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• Maintain a single point of contact for the member to ensure coordination of all services

and monitoring of treatment.

• Maintain face-to-face and telephonic meetings with the member to ensure appropriate

support of the member’s goals and foster independence.

• Coordinate and provide access to specialists, as needed; relevant long-term specialty

providers, relevant emergency resources, relevant rehabilitation therapy services,

relevant non-Medicaid services, etc.

• Education regarding service delivery through Medicare and/or Medicaid.

• Measure and evaluate outcomes designated in the CCP and monitor progress to ensure

covered services are being received and assist in resolution of identified problems.

• Achieve coordination of physical, BH, and LTC services.

• Maintain consistent communication and contact with member’s PCP, specialists, and

other individuals involved in the member’s care. The MCO shall maintain consistent

communication and contact with the assigned CYFD permanency placement worker

(PPW) for protective services involved children and youth, juvenile probation officer

(JPO) for juvenile justice involved youth, and community behavioral health clinician

(CBHC) for CYFD involved children and youth.

• Maintain and monitor the member’s CB and provide assistance with complex services.

• Consider member and provider input to identify opportunities for improvement.

• Collaborate and/or cooperate with representatives of the Independent Consumer

Support System.

4.8. Staffing Requirements and Delegations

The MCO may utilize a care coordination team approach to perform care coordination activities, with

the MCO’s care coordination team consisting of the member’s primary Care Coordinator and other

individuals with relevant expertise and experience appropriate to address the needs of members. While

the MCO may subcontract the HRA activities, the MCO shall ensure its staff, subcontractor(s), or

vendor(s) conducting the HRA are adequately trained to effectively conduct the HSD standardized HRA.

CNAs must be performed by primary Care Coordinators employed by the MCO or its delegate. The MCO

may delegate some care coordination functions to local resources, such as: PCMHs, FQHCs, CHWs, CHRs,

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school-based health centers [SBHCs], Correctional Facilities, CSAs, Paramedicine programs, county

entities, Centers for Independent Living, and Tribal entities. The MCO will implement policies and

procedures that will define and specify the qualifications, experience, and training of each member of

the MCO care coordination team and its delegated Care Coordinators to ensure specific functions are

performed by a qualified Care Coordinator.

Maximum caseload per Care Coordinator, are established by HSD and shall not be exceeded by the

MCO. As the MCO transitions more care coordination functions to the provider level, it will collaborate

with HSD to adjust care coordination caseload requirements. Caseload to Care Coordinator ratios are as

follows:

• CCL2:

o Members not residing in a NF 1:75; and

o Members residing in a NF 1:125.

• CCL3:

o Members not residing in a NF 1:50; and

o Members residing in a NF 1:125.

• Care coordination for members who participate in the self-directed CB:

o CCL2 is 1:75; and

o CCL3 is 1:50.

MCOs or its delegate shall submit, upon request by HSD, a Care Coordination Staffing Plan, which at a

minimum shall specify:

• The number of Care Coordinators, care coordination supervisors, other care coordination team

members the MCO plans to employ;

• The ratio of Care Coordinators to members;

• The MCO’s plans to maintain ratios as outlined by care coordination level and the explanation of the

methodology used for determining such ratios;

• How the MCO will ensure such ratios are sufficient to fulfill the Agreement requirements;

• The roles and responsibilities for each member of the care coordination team;

• A strategy that encourages the use of Native American Care Coordinators and limits duplication of

services between Indian Health Services, Tribal Health Providers, and Urban Indian Providers (I/T/U)

and non-I/T/U providers;

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• How ratios are adjusted to accommodate travel requirements for those Care Coordinators serving

members in rural/frontier areas of the State and/or for those members that require extraordinary

efforts from the assigned Care Coordinator; and

• How the MCO will use Care Coordinators to meet the needs of New Mexico’s unique population.

The MCO or its delegate shall ensure members have a telephone number for direct contact with their

Care Coordinator and/or a member of their care coordination team, (without being routed through

several contact points), during normal business hours (8:00 a.m. – 5:00 p.m. Mountain Standard Time).

When the member’s Care Coordinator or a member of the member’s care coordination team is not

available, the call shall be answered/facilitated by another qualified staff person in the MCO’s or its

delegate’s care coordination unit. Calls requiring immediate attention shall be “warm” transferred

directly to another Care Coordinator, not letting the call go to voice mail. After normal business hours,

calls requiring immediate attention by Care Coordinator shall be handled by the member services line,

as stipulated by Section 4.15.1 of the Agreement.

When Native American members request a Native American Care Coordinator, the MCO must employ or

contract with a Native American Care Coordinator or contract with a CHR to serve as the Care

Coordinator.

The MCO or its delegate must accommodate the member’s requests to change to a different Care

Coordinator if desired and if there is an alternative Care Coordinator available. Such availability may take

into consideration the MCO’s or its delegate’s need to efficiently deliver care coordination in accordance

with the requirements in the Agreement. In ensuring quality and continuity of care the MCO or its

delegate shall make efforts to minimize the number of changes in a member’s Care Coordinator. The

MCO or its delegate may need to initiate change in the following circumstances:

• Assigned Care Coordinator is no longer employed by the MCO or its delegate;

• There is a conflict of interest preventing neutral support for the member;

• Care Coordinator is on temporary leave from employment; or

• Caseload of the assigned Care Coordinator must be adjusted due to its size or intensity.

The MCO or its delegate shall develop policies and procedures regarding notice to members of Care

Coordinator changes initiated by either the MCO or its delegate, or the member, including notice of

planned Care Coordinator changes initiated by the MCO or its delegate.

The MCO or its delegate shall ensure continuity of care when Care Coordinator changes are made. The

MCO or its delegate shall demonstrate use of best practices by encouraging newly assigned Care

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Coordinators to attend a face-to-face transition visit with the member and the out-going Care

Coordinator, when possible, and include documentation of such transition in the member’s file.

Initial training shall be provided by the MCO or its delegate to newly hired Care Coordinators and

ongoing training provided at least annually to all Care Coordinators. Involvement of New Mexico Tribes

as training instructors should be utilized where appropriate.

4.9. Engagement of Members

HSD recognizes there may be a select few managed care members who present challenges to the service

delivery system due to the complexity of their needs. This policy is designed for members who

demonstrate inappropriate behaviors and/or frequent contact of State and MCO staff, and/or have been

unresponsive to traditional care coordination efforts and noncompliant with recommended BH services.

This group of “high health risk/high resource utilization” (HHR/HRU) is different than other populations

and individuals in the care system because denying or delaying care to them has significant immediate

negative consequences to their health and safety. The risk to the individual can be documented in

assessments, contact notes, and care plans. Responding to the challenges presented by this category of

members requires monitoring of attempted delivery of care, documenting interactions, and thresholds

of behavior or conditions that escalate events to a higher level of response and identifying appropriate

teams to design and implement responses. Consistent, well-crafted responses to concerns are essential

when providing care or addressing resistance to care. This will minimize excessive use of State, MCO, and

provider resources, as well as minimizing risk to the individual’s health and safety.

The following protocol is to be utilized across MCOs, agency providers, and State employees and

programs for each recipient identified as part of the HHR/HRU population. The expected result is a more

efficient use of resources to achieve an optimal outcome for the individual. This is intended to free time

and energy to manage all complex individuals in the care system and to achieve optimal levels of health

and safety for all individuals.

Intervention Procedures/Policies: Care delivery literature recommends the use of behavioral contractual

agreements with members so all parties agree on appropriate responses in a non-compliant care

situation. The State may partner with MCOs to make this intervention consistent for all MCOs and all

individuals identified as HHR/HRU.

At the threshold of risk agreed upon by the MCO, a meeting is arranged with the individual and

appropriate recipients of the care team. For CYFD involved clients, include the CYFD community

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behavioral health clinician (CBHC) and the child’s PPW. This team must include the Care Coordinator, a

management level staff of the MCO and a high-level clinical staff member of the MCO. The member may

request one or two people to be in attendance. The intention of the meeting with the participant is to:

• Establish/discuss optimal outcome for health and safety;

• Identify the issues interfering with optimal health and safety outcomes;

• Clarify roles for each member of the team;

• Clarify rules of engagement (who can call whom and when, etc.) and program regulations;

• Assign tasks to each team member with timeline;

• Sign agreement that documents the discussion and assignment of tasks and holds each member

accountable;

• Schedule 2nd meeting within two weeks. Second meeting is a final meeting. Review tasks.

Discuss/establish consequences of any failure to deliver on tasks. Sign contract/care plan. (Includes

updates weekly and addressing ongoing/emergent issues at a bi-monthly meeting.)

• Schedule updates between participants, MCO staff on a regular basis; and

• Ensure maintenance of documentation is with MCO, participant, and natural supports.

When HHR/HRU recipients are identified, the MCOs will designate one point of contact and communicate

that point of contact to HSD/MAD and other involved individuals. If the identified recipient calls

HSD/MAD or other agencies, the individual will be referred back to the MCO point of contact.

If the process outlined above does not provide resolution, the MCOs will utilize their complex case team

and complex case rounds protocol.

4.10. MCO Care Coordination with 1915(c) HCBS Waivers: Developmental Disabilities (DD), Mia Via, and

Medically Fragile (MF) Waivers

The MCOs provide acute and ancillary medical and BH services to the 1915 (c) HCBS recipients/MCO

members. The MCO is responsible for ensuring a CCP is initiated upon enrollment and assigning a Care

Coordinator for coordinating all services in the MCO CCP. The MCOs are required to perform all care

coordination functions described in this Manual section including but not limited to: capturing the

member’s medical, BH, and ancillary needs; explaining to the member, family, and/or guardian, the

Medicaid benefits that are available from the MCO, and how the MCO care coordinator can assist with

coordinating services with the case manager or consultant; developing a CCP; and completing all

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required touch points identified by the member’s current care coordination level. Exceptions to care

coordination functions are specifically described below for members receiving 1915(c) HCBS waiver

services.

4.11. Overview of Medicaid 1915(c) HCBS Waiver Programs

• Developmental Disabilities Waiver (DDW) Program

The DDW provides an array of HCBS to help individuals with developmental and/or intellectual

disabilities to remain in their homes and communities as opposed to institutional care, become

more independent, and reach their personal goals. The DDW serves individuals who meet an

Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) LOC. DDW individuals

have a Medicaid Category of Eligibility (COE) 096.

The DDW provides the following HCBS: behavior support consultation; case management;

community integrated employment services; customized community supports; customized IHS;

crisis support; environmental modification; independent living transition service; intensive medical

living supports; living supports; non-medical transportation; nutritional counseling; personal support

technology; preliminary risk screening and consultation related to inappropriate sexual behavior;

adult nursing; respite; socialization and sexuality education; supplemental dental care; and skilled

therapies. DDW services are supplementary to early periodic screening, diagnostic, and treatment

(EPSDT) benefits for recipients under the age of 21.

DDW services and budgets are outlined in the recipient's Individual Service Plan (ISP). The ISP is

developed through a person-centered planning process which allows recipients to select services

that will help them achieve personally defined outcomes in the most integrated community setting.

The ISP is created by the DDW recipient with the assistance of their DDW case manager and the

DDW Interdisciplinary team (IDT). The DDW case manager provides information, support, guidance,

and assistance to recipients during the Medicaid eligibility process and afterwards during the ISP

development. The IDT serves to help the recipient identify supports, services and goods that meet

their need for DDW services and are specific to the recipient’s qualifying condition.

• Mi Via Self-Directed Waiver Program

Mi Via is the State of New Mexico’s self-directed waiver program serving individuals who meet an

ICF-IID LOC. Medicaid members served through the Mi Via waiver are referred to as “participants”.

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Mi Via participants are identified with either COE 095 Medically Fragile or COE 096 Developmental

Disability and a Setting of Care (SOC) of “MIV”. The goal of Mi Via is to provide home and

community-based alternatives that facilitate greater participant choice and control over the types of

services and supports they receive. It is important to distinguish that Mi Via is a self-directed waiver

program that is operated separately from the Centennial Care Self-Directed Community Benefit

(SDCB) Program.

Mi Via provides the following services: consultant/support guide services; behavior support

consultation; community direct support; customized community supports; in-home living supports;

emergency response network; Employment Supports services; environmental modification services;

Home Health Aide; homemaker/direct support services; nutritional counseling; personal plan

facilitation; private duty nursing for adults; respite; skilled therapies for adults; specialized therapies;

related goods; and non-medical transportation. Mi Via services are supplementary to EPSDT benefits

for participants under the age of 21 years old.

Mi Via waiver services and budget are outlined in the participant's Service and Support Plan (SSP).

The SSPs are developed through a person-centered planning process which allows participants to

select services that will help them achieve personally defined outcomes in the most integrated

community setting. The SSP is created by the Mi Via participant with the assistance of their

consultant. Consultants provide information, support, guidance, and assistance to participants

during the Medicaid eligibility process and afterwards during SSP development. Consultants serve to

help the participant identify supports, services, and goods that meet their need for Mi Via waiver

services and are specific to the participant’s qualifying condition. The level of support a consultant

provides is unique to the individual participant and their ability to self-direct in the Mi Via program.

• Medically Fragile Waiver (MFW) Program

The MFW serves individuals who have been diagnosed with an MF condition defined as a life

threatening, chronic condition which results in a prolonged dependency on skilled nursing care at

home. MFW individuals have a Medicaid COE 095. MFW recipients meet an ICF/IID LOC, as well as

established MF parameters.

The MFW provides the following HCBS: RN case management; private duty nursing (RN, licensed

practical nurse [LPN]); home health aide; behavior support consultation; respite care; nutritional

counseling; skilled therapies (physical, occupational, and speech) for adults; environmental

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modifications; and specialized medical equipment. MFW services are supplementary to EPSDT

benefits for recipients under the age of 21.

The UNM Health Sciences Center, Center for Development and Disability has a Medically Fragile

Case Management Program (MFCMP) that currently provides RN/case management services to both

MF waiver and non-waiver (EPSDT) MF persons statewide. Case managers from the UNM/MFCMP

assess the recipient for MF parameters, compile the MFW LOC forms, and submit the MFW LOC

packet to the Medicaid Third Party Assessor (TPA) for an ICF/IID LOC determination. Case Managers

also create the MFW recipient’s ISP that includes services and budget amounts determined by the

LOC.

4.12. MCO Care Coordination Activities and the 1915(c) HCBS Waivers Service Plan (ISP or SSP)

• Members who transition from Community Benefits to a 1915 (c) HCBS Waiver

o Coordination between the MCO and 1915 (c) Waiver program must be coordinated to avoid

gaps in home and community-based services (i.e. Community Benefits and 1915 (c) Waiver)

during the transition.

o The MCO Care Coordinator shall work proactively with the member and member’s 1915 (c)

case manager/consultant to coordinate the transition dates for the member to move

seamlessly from Community Benefits to the 1915 (c) waiver service plan.

• Members in the DD Waiver program

o The MCO Care Coordinator shall request a copy of the approved DDW LOC packet,

consisting of the Intermediate Care Facility for Individuals with Intellectual Disabilities

(ICF/IID) abstract (MAD 378 form) and related waiver assessments from the Medicaid TPA

for the purpose of obtaining a complete, comprehensive picture of the recipient and their

needs.

o A Client Information Update (CIU) form/MAD 054 is faxed to the TPA to request the LOC

packet.

o The MCO Care Coordinator cannot make changes to the member’s DDW ISP and Budget.

o The MCO will not complete a NF LOC on members enrolled in the DD 1915 (c) waiver, unless

the member is transitioning from the community to a nursing facility for long-term care

permanent placement. The MCO shall inform the member’s DDW case manager in the event

of a NF long-term permanent placement.

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o The MCO will utilize the DDW LOC and CIA information obtained from the Medicaid TPA to

complete certain portions of the CNA prior to initiating a visit with the member.

o The MCO Care Coordinator shall have knowledge that while the MCO is responsible for

annual CNA visits, the DD waiver case manager assists the member with the DD waiver LOC

assessment process and ISP and Budget development. The MCO Care Coordinator shall

utilize only the PH and BH portion of the MCO’s CCP for members who are receiving HCBS

through the DD waiver.

• MCO members in the Mi Via Self-Directed Waiver Program

o The MCO Care Coordinator shall request a copy of the approved Mi Via LOC packet,

consisting of the abstract (MAD 378 form) and related assessments from the TPA for the

purpose of obtaining a complete, comprehensive picture of the participant and their needs.

o A CIU/MAD 054 form is faxed to the Medicaid TPA to request the LOC abstract and CIA.

o The MCO Care Coordinator cannot make changes to the member’s Mi Via SSP and Budget.

o The MCO will not complete a NF LOC on members enrolled in the Mi Via 1915 (c) Waiver,

unless the member is transitioning from the community to a nursing facility for long-term

care permanent placement. The MCO shall inform the member’s Mi Via consultant in the

event of a NF long-term permanent placement.

o The MCO Care Coordinator will utilize the LOC and CIA information obtained from the

Medicaid TPA to complete certain portions of the CNA prior to initiating a visit with the

member.

o The MCO Care Coordinator shall have knowledge that while the MCO is responsible for the

annual CNA visits, the consultant assists the participant with the annual Mi Via waiver LOC

assessment process (which requires the TPA to conduct an in-home assessment of

long-term HCBS needs). The MCO and consultant are encouraged to coordinate the CNA

visits and LOC in-home assessment at the same time in order to reduce the burden to the

participant/member and the participant’s family.

o The MCO Care Coordinator shall utilize only the PH and BH portion of the MCO’s CCP for

members who are receiving HCBS through the Mi Via waiver.

• MCO Members in the MFW Program

o The MCO Care Coordinator shall request a copy of the approved MFW LOC packet and ISP

packet from the MFW case management agency prior to the completion of the CNA. The

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MCO will utilize the LOC and ISP information to complete as much of the CNA as possible

prior to the visit.

o The MCO shall ensure the MFW ISP serves as the CCP for the MF member.

o The MCO shall work with the MFW case management agency to coordinate MFW LOC

assessments and/or CNA visits at the same time in order to reduce the burden on these

families.

o The MCO will not complete an NF LOC on members enrolled in the MF 1915(c) Waiver,

unless the member is transitioning from the community to a nursing facility for long-term

care permanent placement. The MCO shall inform the member’s MFW case manager in the

event of a NF long-term permanent placement.

o Not be required to conduct a monthly/quarterly face-to-face or telephonic contact for the

MF members. The MFW case management agency will conduct monthly visits and provide

the MCO with copies of the visit notes. The MCO will review the visit notes monthly and

update the CNA as needed.

o Conduct the required annual in person visit and CNA for MF members.

o Utilize the MFW ISP as the CCP for the MFW recipient.

4.13. MCO Care Coordination Activities for MF EPSDT (Non-Waiver) Members Case Managed by the MFW

Case Management Agency

The MCOs are contracted with the MFW case management agency to continue to provide RN/case

management services for those individuals (non-waiver) who meet the MF criteria. The same MF

parameters are utilized for non-waiver members.

For MF EPSDT (non-waiver) clients, the MCO Care Coordinator shall:

• Request a copy of the approved MF ISP from the MFW case management agency prior to the

completion of the CNA. The MCO will utilize the information in the ISP to complete as much of the

CNA as possible prior to the annual visit.

• Not complete a NF LOC assessment on MF EPSDT members.

• Ensure the MF ISP serves as the CCP for the MF member.

• Work with the MFW case management agency to coordinate the CNA in-person visits at the same

time in order to reduce the burden on these MF members and families.

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• Not be required to conduct a monthly/quarterly face-to-face or telephonic contact for the MF

members. The MFW case management agency will conduct monthly visits or phone conference calls

with the MCO Care Coordinator and provide the MCO with copies of the visit notes. The MCO will

review the visit notes monthly and update the CCP as needed.

• Conduct the required annual in-person visit and CNA for MF members.

4.14. Transitions from the HSD Non-Medicaid Brain Injury Services Fund to a Centennial Care MCO

The HSD Brain Injury Services Fund (BISF) offers short-term non-Medicaid services to individuals with a

confirmed diagnosis of brain injury, either traumatic brain injury (TBI) or other acquired brain injury.

The MCO shall implement policies and procedures for ensuring members with brain injury transition

from the BISF into benefits and services that are covered under the MCO. The MCO will follow all care

coordination requirements as applicable. The MCO may contact the HSD BISF service coordination

contractor to verify the status of a member’s BISF eligibility. Upon enrollment with the MCO, all BISF

service coordination requirements transfer to the MCO. At a minimum, the following must be

addressed:

• The MCO shall maintain ongoing communication, enlist the involvement of, and coordinate with

BISF service coordinators to affect the full transition of the member’s care from the BISF to the

MCO.

o The HRA shall include questions about specific health diagnoses, including brain injury.

o For members who identify as having brain injury during the HRA, opportunity shall be given to

reschedule the HRA when natural supports and advocates, including a BISF service coordinator

can be presented. During any HRA, information shall be requested by the reviewer about the

member’s specific needs and what services were assessed as needed through the BISF or its

currently contracted providers.

o An HRA containing information about a self-reported brain injury shall trigger the scheduling of

a CNA to include the person with the brain injury, any natural supports or advocates, and the

BISF service coordinator or BISF life skills coach, as applicable.

o All parties are to ensure a Release of Information has been signed by the member to affect the

participation of the BISF service coordinator and/or other identified advocates in the member’s

transition.

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o The MCO Care Coordinator is to acquire a copy of the BISF participant’s BISF assessment and

Independent Living Plan (ILP) from the BISF service coordinator to ensure their inclusion in the

member’s file. These efforts are intended to preserve the history of brain injury and ensure that

care needs are related to the brain injury diagnosis.

• The MCO shall receive brain injury training by the HSD including: general brain injury information;

available state and community resources; and communication strategies. Other topics may include:

how to conduct assessments that capture the needs of brain injury; and how to develop a CCP that

considers the needs of members with brain injury. Training by the MCO shall be required for any

new care coordination staff within three months of employment, with renewed training to occur on

a two-year schedule.

Section 4: Care Coordination

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January 1, 2019; October 1, 2020

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4.15. Appendix

4.15.1. Health Risk Assessment

Section 4: Care Coordination

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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Section 5: Transitions of Care

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January 1, 2019; October 1, 2020

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5. Transitions of Care

5.1. General Information

In managed care, HSD will continue its commitment to providing the necessary supports to assist

members as they transition under various circumstances.

The MCOs must identify and facilitate coordination of care for all members during various transitions

including but not limited to:

• Transition from an NF to the community;

• Transition for member(s) with special circumstances;

• Transition for member(s) moving from a higher LOC to a lower LOC;

• Transition for member(s) turning 21 years of age;

• Transition for member(s) changing MCOs while hospitalized;

• Transition for member(s) changing MCOs during major organ and tissue transplantation services;

• Transition for member(s) changing MCOs while receiving outpatient treatment for significant

medical conditions;

• Transition for member(s) changing MCOs;

• Transition for member(s) previously in FFS;

• Transition for member(s) moving from a residential placement or institutional facility (including

psychiatric hospitals) to a community placement;

• Transition for children entering or returning home from a foster care placement;

• Transition for member(s) released from incarceration or detention facilities;

• Transition for member(s) moving from an out-of-state placement to an in-state placement;

• Transition from RTC to TFC, group home or foster care.

• Transition for member(s) discharging from a hospital;

• Transition for member(s) discharging from out-of-home placements (ARTC, RTC, Group Home,

Therapeutic Foster Care [TFC]) and crisis centers related to BH treatment; and/or

• Transition for member(s) who are preparing to receive out-of-state treatment.

Section 5: Transitions of Care

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

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5.2. Transitions of Care

The MCOs shall develop and implement methods for identifying and facilitating care coordination for all

members involved in various transition scenarios. Such methods shall include, at a minimum:

• The CNA;

• Preadmission Screening and Resident Review (PASRR);

• MDS;

• Provider referrals to or from hospitals and RTCs;

• Ombudsman;

• Family member;

• Change in medical status;

• Member self-referral;

• Community Reintegration Allocation received;

• A recommendation from the Individualized Planning Meeting Plan for a child or youth in CYFD PS

custody;

• State Agency Referral; and/or

• Incarceration or detention facility referral.

If a member is a candidate for transitioning to the community, the Care Coordinator shall facilitate the

development of and implementation of a transition plan which must be labeled “Transition of Care Plan”

and may be a stand-alone document or included in the CCP. If included as a part of the CCP, the

“Transition of Care Plan” must be clearly labeled for MCO tracking and HSD auditing. The transition of

care plan shall remain in place for a minimum of 60 calendar days from the date of the decision to

pursue transition or until the transition has occurred and a new CCP is in place. The transition of care

plan shall address the member’s transitional needs including but not limited to:

• PH and BH needs;

• CB needs;

• Continuation of Medicaid eligibility;

• Selection of providers in the community;

• Housing needs;

• Financial needs;

• Interpersonal skills (the social skills people use to interact effectively with other people, including

the ability to convey one’s needs); and

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• Safety.

The Care Coordinator shall conduct an additional assessment within 75 calendar days after the transition

to determine if the transition was successful and to identify any remaining needs resulting in a new CCP

or modifications to an existing CCP.

If the member has an existing full Medicaid category of assistance, other than Institutional Care, an

allocation is not needed to reintegrate into the community. The reintegration process can be completed

and CBs can be provided with the full Medicaid category.

If the member is Not Otherwise Medicaid Eligible (NOME), and in an NF and wishes to receive services in

the community, a Community Reintegration (CRI) allocation must be requested by contacting the Aging

and Long-Term Services Department, Aging and Disability Resource Center (ALTSD/ADRC), prior to

discharge (see Section 7: Community Benefits). The Care Coordinator must assist the member in gaining

eligibility for a CB category of assistance, and ensure services are authorized and in place for a safe and

seamless discharge.

5.3. Transitions of Care Requirements

The MCO shall establish policies and procedures to ensure all members are contacted in a timely

manner and are appropriately assessed using HSD prescribed time frames, processes and tools, to

identify needs.

The MCO shall coordinate with the discharge planning teams at hospitals and institutions (e.g., NFs,

jails/prisons, juvenile detention centers and CYFD secure facilities, RTCs, psychiatric hospitals, behavioral

health facilities) to address at a minimum:

• Need for HCBS;

• Follow up appointments;

• Therapies and treatments;

• Medications; and/or

• DME.

The MCO shall notify the assigned CYFD permanency placement worker (PPW) for protective services

(PS) involved children and youth and juvenile probation officer (JPO) for juvenile justice-involved youth,

and community behavioral health clinician (CBHC) within 30 Business Days prior to transition in care for

CYFD-involved children/youth. Precipitous discharge from these placements is prohibited.

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The MCO shall perform an in-home assessment for members who are transitioning from an inpatient

hospital or NF stay within three calendar days after the transition. The assessment will address at a

minimum:

• Safety in home environment;

• PH needs;

• BH needs;

• Housing needs;

• Continuation of Medicaid eligibility;

• Financial needs;

• CNA if one is not in place; and

• CB needs and services in place.

The MCO shall contact the member monthly for three months to ensure continuity of care has occurred

and the member’s needs are met. The MCO shall not transition members to another provider for

continuing services unless the current provider is not a contract provider. The MCO shall facilitate a

seamless transition to new services and/or providers, without any disruption in services as outlined in

the CCP.

For members who are preparing to receive out-of-state treatment, the MCO shall ensure daily updates

are provided to the member and/or AR about the status of the out-of-state provider agreement and

authorized treatment plan until treatment begins.

The MCO shall maintain active communication with the member and/or AR once out-of-state treatment

begins, including weekends and holidays, for the duration of the treatment. The MCO shall resume care

coordination activities pursuant to 4.4 of the Agreement following treatment completion and member’s

return to New Mexico.

5.4. Transition of Care Requirements for Pregnant Women

In the event a member enrolling with an MCO is in her second or third trimester of pregnancy and is

receiving medically necessary covered prenatal care services prior to enrollment in the MCO, the MCO

shall be responsible for providing continued access to the prenatal care provider (whether contract or

non-contract provider) through the postpartum period, without any form of prior approval.

In the event a member enrolled with an MCO is in her first trimester of pregnancy and is receiving

medically necessary covered prenatal care services prior to enrollment, the MCO shall be responsible for

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the costs related to the continuation of such medically necessary prenatal care services. This includes

the delivery, without any form of prior approval and without regard to whether such services are being

provided by a contract or non-contract provider. This coverage is required for up to 60 calendar days

from the member’s enrollment or until the member may be reasonably transferred to a contract

provider without disruption in care, whichever is less.

If the member is receiving services from a contract provider, the MCO shall be responsible for the costs

of continuation of medically necessary covered prenatal services from that provider, without any form

of prior approval, through the postpartum period.

If the member is receiving services from a non-contract provider, the MCO shall be responsible for the

costs of continuation of medically necessary covered prenatal services, without any form of prior

approval, until such time as the MCO can reasonably transfer the member to a contract provider

without impeding service delivery that might be harmful to the member’s health in accordance with

Section 4.4.16.3 of the Agreement.

5.5. Transfer from the Health Insurance Exchange

The MCO must minimize disruption of care and ensure uninterrupted access to medically necessary

services for individuals transitioning between Medicaid and qualified MCO coverage on the Health

Insurance Exchange.

At a minimum, the MCO shall establish transition guidelines for the following individuals:

• Pregnant women;

• Individuals with significant health care needs or complex medical conditions;

• Individuals receiving ongoing services or who are hospitalized at the time of transition; and

• Individuals who received prior authorization for services from its qualified MCO.

The MCO is expected to coordinate services and provide phase-in and phase-out time periods for each

of these individuals, and to maintain written policies, procedures, and documentation to address

coverage transitions.

5.6. Transitions of Care for Members Moving from a Higher LOC to a Lower LOC

The MCO shall develop and implement policies and procedures for ensuring that members transition

successfully from higher levels of care (e.g., acute inpatient, residential treatment centers, social

detoxification programs, treatment foster care, etc.) to the most appropriate lower LOC. Transitions

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from inpatient and BH residential treatment facilities for both children and adults must be addressed. At

a minimum, the following must be addressed:

• Maintain on-going communication, enlist the involvement of and coordinate with state-run facilities

to monitor and support their participation in the member’s care.

• Care Coordinators must be knowledgeable of non-Medicaid BH and PH programs/services,

statewide, available to its members in order to facilitate referrals, coordinate care, and ensure

transition to community-based services.

• Ensure members receive follow-up care within seven calendar days of discharge from a higher LOC

to a lower LOC but receive follow up care no longer than 30 calendar days following other

discharges.

5.7. Transitions of Members Turning 21 Years of Age

All members, including those who are under the care of EPSDT, must be transitioned to other services

on their 21st birthday. The Care Coordinator must initiate a transition plan by the age of 20 years, which

is ongoing until the member leaves the EPSDT program. The transition plan must be labeled “Transition

of Care Plan” and may be a stand-alone document or included in the CCP. If included as part of the CCP,

the “Transition of Care Plan” must be clearly labeled for MCO tracking and HSD auditing. The transition

plan must:

• Establish a plan that is age appropriate and addresses the transition needs of the member:

o Health condition management;

o Developmental and functional independence;

o Education;

o Social and emotional health;

o Continuity of behavioral health services, if requested;

o Guardianship; and

o Transportation.

• Ensure members and, when authorized, family members, guardians and PCPs are part of the

development and implementation of the transition plan. The MCO shall also ensure that the

assigned CYFD permanency placement worker (PPW) and/or youth transition specialist for

Protective Services (PS) involved children and youth, juvenile probation officer (JPO) or transition

coordinator for juvenile justice involved youth, and community behavioral health clinician (CBHC)

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for CYFD involved children/youth are part of the development and implementation of the transition

plan for CYFD involved children/youth.

• Document the transition plan in the medical record.

• Provide the member, and when authorized, family members and guardian with a copy of the

transition plan.

• Establish a timeline for completing all services the member should receive through EPSDT prior to

his or her 21st birthday.

• Review and update the plan and timeline with the member, and when authorized, the guardian and

family prior to official transition to adult provider.

• Advise the member’s PCP of the discharge and ensure coordination of the services with the adult

PCP.

5.8. Transition for Members changing MCOs while Hospitalized

The MCO will make provisions for the smooth transition of care for members who are hospitalized on

the day of an enrollment change. The provisions must include policies for the following:

• Authorization of treatment by the receiving MCO on an individualized basis. The receiving MCO

must address contracting for continued treatment with the institution on a negotiated fee basis, as

appropriate.

• Notification to the hospital and attending physician of the transition by the relinquishing MCO. The

relinquishing MCO must notify the hospital and attending physician of the pending transition prior

to the date of the transition and instruct the providers to contact the receiving MCO for

authorization of continued services. If the relinquishing MCO fails to provide notification to the

hospital and the attending physician relative to the transitioning member, the relinquishing MCO

will be responsible for coverage of services rendered to the hospitalized member for up to 30

calendar days. This includes, but is not limited to, elective surgeries for which the relinquishing MCO

issued prior authorization.

• Coordination with providers regarding activities relevant to concurrent review and discharge planning must

be addressed by the receiving MCO, along with the mechanism for notification regarding pending discharge.

• Transfer of care to a physician and/or hospital affiliated with the receiving MCO. Transfers from an

out-of-network provider to one of the receiving MCO providers cannot be made if harmful to the

Section 5: Transitions of Care

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member's health and must be determined medically appropriate. The transfer may not be initiated

without approval from the relinquishing MCO PCP, or the receiving MCO Medical Director.

Note: Members in Critical Care Units, Intensive Care Units, and Neonatal Intensive Care Units require

close consultation between the attending physician and the receiving MCO physician. If a member is

admitted to an inpatient facility while still assigned to the relinquishing MCO, and discharged after

transition to the receiving MCO, both must work together to coordinate discharge activities.

The relinquishing MCO will be responsible for coordination with the receiving MCO regarding each

specific prior authorized service. For members known to be transitioning, the relinquishing MCO will not

authorize hospital services such as elective surgeries scheduled less than 15 calendar days prior to

enrollment with the receiving MCO. If authorized to be provided during this time frame, the service for

the transitioning member will be the financial responsibility of the MCO who authorized the service.

5.9. Transition for Members Changing MCOs during Major Organ and Tissue Transplantation Services

If there is a change in MCO enrollment, both the relinquishing and receiving MCOs will be responsible

for coordination of care and coverage for members awaiting major organ or tissue transplantation from

the time of transplantation evaluation and determination through follow-up care after the

transplantation surgery. If a member changes MCO enrollment while undergoing transplantation at a

contracted transplant center, the relinquishing MCO is responsible for contracted components or

modules of the service up to and including completion of the service modules that the member is

receiving at the time of the change. The receiving MCO is responsible for the remainder of the module

components of the transplantation service.

If a member changes to a different MCO while undergoing transplantation at a transplant center that is

not a contracted provider, each MCO is responsible for its respective dates of service (DOS). If the

relinquishing MCO has negotiated a special rate, it is the responsibility of the receiving MCO to

coordinate the continuation of the special rate with the respective transplant center.

5.10. Transition for Members Changing MCOs while receiving Outpatient Treatment for Significant Medical

Conditions

MCOs must have protocols for ongoing care of active and/or chronic "high risk" (e.g., outpatient

chemotherapy, home dialysis, etc.) members and pregnant members during the transition period. The

receiving MCO must have protocols to address the timely transition of the member from the

relinquishing PCP to the receiving PCP, in order to maintain continuity of care.

Section 5: Transitions of Care

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The receiving MCO must address methods to continue the member's care, such as contracting on a

negotiated rate basis with the member's current provider(s) and/or assisting members and providing

instructions regarding their transfer to providers affiliated with the receiving MCO.

Receiving MCOs are also responsible for coordinating the transition of pregnant women to maintain

continuity of care. Pregnant women who transition to a new MCO within the last trimester of their

expected date of delivery must be allowed the option of continuing to receive services from their

established physician and anticipated delivery site.

5.11. MCO Requirements for Members Transitioning between MCOs

For any member transitioning from one MCO to another the following must occur.

• The relinquishing MCO must provide relevant information regarding members who transition to a

receiving MCO.

• The MCO must also provide protocols for the transfer of pertinent medical records, as discussed in

this policy, and the timely notification of members, subcontractors, or other providers, as

appropriate during times of transition.

• The receiving MCO must provide new members with their handbook and emergency numbers

within 10 calendar days of transition for acute care members and within 12 calendar days of

transition for all other members (allows for care coordination on-site visit).

• If a member is referred to and approved for enrollment, the relinquishing MCO must coordinate the

transition with the receiving MCO to ensure applicable protocols are followed for any special

circumstances of the member, and that continuity and quality of care is maintained during and after

the transition.

• The relinquishing MCO that fails to notify the receiving MCO of transitioning members with special

circumstances, or fails to send the transition notification, will be responsible for covering the

member's care resulting from the lack of notification, for up to 30 calendar days.

• The MCO shall ensure that any member entering the MCO has access to services consistent with the

access they previously had and is permitted to retain their current provider for a period of time, if

that provider is not contracted with the MCO.

Section 5: Transitions of Care

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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5.12 Transitions of Care for Justice Involved Members

The MCO shall develop and implement policies and procedures for ensuring that members released

from incarceration or detention facilities transition successfully back into the community. At a minimum,

MCOs must:

• Initiate an HSD approved Transition of Care (TOC) assessment with the member prior to member’s

release or within three (3) business days of notification of member’s release.

• Develop a TOC plan, derived from the TOC assessment, with member and/or member’s

representative’s participation, that addresses, at a minimum:

• Physical and Behavioral Health needs;

• Community Benefit needs;

• Selection of Providers in the community;

• Housing needs;

• Financial needs;

• Continuation of Medicaid eligibility

• Interpersonal skills; and

• Safety

The Transition of Care plan shall remain in place for a minimum of sixty (60) calendar days from the

member’s release or sixty (60) calendar days from notification of member’s release.

• Conduct a Health Risk Assessment (HRA) within three (3) business days of member’s release or

three (3) business days of notification of member’s release unless the member has had one within

the past thirty (30) calendar days.

• Complete a Comprehensive Needs Assessment (CNA), within thirty (30) business days of member’s

release or within thirty (30) business days of notification of member’s release, if warranted by the

completed HRA, to determine if the member should be assigned to Care Coordination level two (2)

or level three (3).

• If the member is leveled at CCL2 or CCL3, follow all contract requirements for ongoing care

coordination including development of a Comprehensive Care Plan and required touchpoints

pursuant to the Medicaid Managed Care Services Agreement 4.4.

• Contact the member monthly for three (3) months after member’s release to ensure continuity of

care has occurred and that the member’s needs have been met.

• Conduct an additional assessment within seventy-five (75) calendar days of member’s release to

determine if the transition was successful and identify any remaining or ongoing needs.

Section 5: Transitions of Care

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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5.13 Transitions of Care for Substance Exposed infants

The MCO shall develop and implement policies and procedures to ensure care coordinators assist in

addressing the needs of pregnant mothers and fathers with opioid use disorders and their infants. Once

the member is referred to the MCO by DOH or a hospital, the MCO care coordinator will be responsible

for assessing, referring, and coordinating support services identified in the Plan of Care. MCO care

coordinators are responsible for collaborating and coordinating care for the infant, affected

mother/father and family and caregivers in accordance with the Children, Youth and Families

Department (CYFD).

At a minimum, MCOs are responsible for:

• Providing annual training for care coordination staff on the Comprehensive Addiction and

Recovery Act (CARA) Plan of Care (POC) to address the needs of both the pregnant women with

opioid use disorders and their substance-exposed newborns. Training to include the difference

between CYFD notification and CYFD referral or report;

• Coordinating care with the CYFD case worker, in cases where a child protective services case is

determined necessary;

• Ensuring care coordination staff communicate and collaborate with hospital staff on

implementation of the POC;

• Obtaining a copy of the POC from the hospital discharge planner;

• Ensuring MCO care coordination staff introduce support service providers identified in the POC

to the infant and mothers including family and caregivers;

• Conducting a Health Risk Assessment (HRA) with the substance abuse-exposed infant, parent or

caregiver within three (3) Business Days of referral to the MCO;

• Completing a Comprehensive Needs Assessment (CNA), within thirty (30) Business Days of HRA

completion to determine if the member(s) should be assigned to Care Coordination level two

(CCL2) or level three (CCL3);

• Following all contract requirements for ongoing care coordination for member(s) leveled at CCL2

or CCL3, including development of a Comprehensive Care Plan (CCP) and required touchpoints

pursuant to section 4.4 of the Medicaid Managed Care Services Agreement and sections 5.2 and

5.3 of the Managed Care Policy Manual; including but not limited to home visitation programs,

early intervention services and recovery supports. MCOs should refer to contract requirements

detailed in sections 4.4.6 and 4.4.7 that include, but are not limited to, high risk pregnancy and

Section 5: Transitions of Care

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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co-morbid health conditions as CCL2 and medically complex and/or untreated substance abuse

dependency as CCL3; and

• Notifying CYFD if the mother and/or family/caregiver(s) are Unable to be Reached, Difficult to

Engage, Refuse Care Coordination, or are non-compliant with the POC and the CCP.

Section 6: Nursing Facilities

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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6. Nursing Facilities (NFs)

6.1. General Information

This policy establishes guidelines for the MCOs regarding NFs. The NF LOC Criteria and instructions can

be found on the HSD website.

6.2. NF Procedures for Requests for Prior Approval

All requests for prior approval shall contain appropriate documentation and must be completed for each

resident for every situation requiring prior approval. All requests for prior authorization are submitted to

the resident’s MCO by fax.

6.3. Pre-Admission Screening and Resident Review (PASRR)

Federal law requires NFs to perform PASRR screens for mental illness, ID, and related conditions. There

are procedures and information that are applicable to all situations requiring prior approval.

• Purpose of PASRR is as follows:

o To determine whether a resident requires a specific level of nursing care;

o To determine if there is suspicion of serious mental illness (SMI) or intellectual disability/related

condition (ID/RC);

o To assess persons suspected of having serious SMI or ID/RC;

o To assess whether specialized services for SMI or ID/RC are needed; and,

o To prevent inappropriate placement in a NF by determining whether the resident is more

appropriately served in a specialized program for those with SMI or ID/RC.

• Organization of the PASRR: PASRR is divided into two levels: Level I Screen and Level II Evaluation.

o Level I Screen: A Level I Screen must be completed prior to admission on every NF applicant. If,

during the Level I Screen, it is determined that the individual is suspected of having either SMI or

ID/RC, a Level II Evaluation or PASRR waiver must occur prior to admission. A Level I Screen must

also be done if there has been a significant change in the physical or mental condition of a

resident who is suspected of having, or previously determined to have SMI or ID/RC. “Significant

change” for PASRR purposes can be tied to the already existing regulatory definition for

significant change that prompts an alteration in a resident’s MDS. Significant change referrals

must be made to the PASRR Unit no later than 21 business days after the occurrence of the

significant change. The PASRR Unit is required to review the completed Level I Screen packet

within seven to nine business days of receipt of the completed packet from the NF. Notification

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January 1, 2019; October 1, 2020

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of the review decision must be submitted to the NF by phone or in writing within that time

period.

o Level II Evaluation: If the Level I Screen identifies a resident who is diagnosed with or suspected

of having SMI or ID/RC, a Level II Evaluation or a PASRR waiver must be completed prior to the

admission of the resident. The Level II Evaluation includes a comprehensive evaluation of the

needs of the resident.

• PASRR Waiver:

o If an individual falls within one of the following categories, a complete Level II Evaluation may

not be performed. A PASRR Waiver is granted on a case-by-case basis.

▪ The resident has a primary diagnosis of dementia.

▪ The resident is being discharged from an acute care hospital for the purpose of convalescent

care medically prescribed for recovery, not to exceed 30 business days.

▪ The resident is suspected of having SMI or ID/RC but is certified to be terminally ill with a life

expectancy of six months or less and is in need of continuous nursing care and/or medical

supervision and treatment due to a physical condition.

▪ The severity of the resident’s medical condition and medical treatment needs are so

extensive that specialized SMI or ID/RC services are not likely to be beneficial.

▪ The resident who is suspected of having SMI or ID/RC and is admitted directly to an NF from

a home for very brief and finite stay (up to 14 days) for the purpose of providing respite to

in-home caregivers.

▪ If APS directly admits an individual to an NF because the individual is in harm’s way, the

PASRR Unit is required to complete the Level II assessment within 10 business days.

• Level I Screen Process

o An NF is required to submit copies of the Level I Screen for each resident with the MDS to the

MCO/Utilization Review (UR) Contractor. The Screen and other necessary documentation must

be sent with the MDS to avoid delays in the review process.

o The MCO/UR Contractor logs in the date on the recipient screen when the MDS, Level I Screen,

and other documentation is received.

o The MCO/UR Contractor scans the Level I Screen. If the resident passes the Screen, the MCO/UR

Contractor determines the NF LOC. If the resident fails the Screen, no further NF LOC action is to

be taken by the MCO/UR Contractor. The MDS Screen, and other documentation, must be

submitted to the PASRR Unit for a Level II determination.

Section 6: Nursing Facilities

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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o The MCO/UR Contractor then sends a notice to the NF that the MDS and other documentation

have been sent to the PASRR Unit for a Level II Evaluation determination.

• Level II Evaluation Process: There are two types of Level II PASRR reviews.

o SMI PASRR II screens are completed by the BHSD contractor for residents living in an NF or

individuals being admitted from a hospital or home to an NF.

▪ The PASRR Unit sends the documents to the BHSD contractor to complete an evaluation and

makes the Level II determination on the review portion of the MDS and the NF LOC

determination, then returns to the PASRR Unit. The PASRR Unit sends the NF LOC

determination and MDS to the NF. The NF then sends the MCO/UR Contractor the MDS and

other documentation with the NF LOC determination if a waiver was not granted.

▪ Within 24 hours of the MCO/UR Contractor receiving the NF LOC determination from the NF

determined by the BHSD contractor, the MCO/UR Contractor transmits the NF LOC

determination via the appropriate interface file.

▪ If a subsequent specified review or significant change review is required, the review portion

of the MDS must be completed by the PASRR Unit. All subsequent reviews follow the

process above by the PASRR Unit instead of the MCO/UR Contractor.

▪ If a subsequent specified review or significant change review is not required, the MDS is

returned to the MCO/UR Contractor for an NF LOC determination.

o ID and RC PASRR II screens are completed by the PASRR Unit for residents living in an NF or

individuals being admitted from a hospital or from home to an NF.

▪ The PASRR Unit completes an evaluation and makes the Level II determination on the

review portion of the MDS and returns the MDS to the NF. The NF then sends the MCO/UR

Contractor the MDS and other documentation for an NF LOC determination if a waiver was

not granted.

▪ All subsequent PASRR Level II reviews are performed by the PASRR Unit unless waived by

the PASRR Unit.

▪ All subsequent NF LOC determinations are made by the MCO/UR contractor.

• PASRR and re-admission from a hospital: The NF contacts the PASRR Unit if the hospitalization of a

resident results in a change in the Level I Screen. If an individual is hospitalized from the NF, the

hospital will complete a new Level I screen prior to discharge.

Section 6: Nursing Facilities

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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• PASRR and Medicaid eligibility pending: If a resident is in a “Pending Medicaid” status at the time of

MDS submission and the resident fails the Level I Screen, the MDS is forwarded to the PASRR Unit as

notification while the following actions occur:

o The NF LOC determination is made by the MCO/UR Contractor.

o The MCO/UR Contractor transmits the NF LOC determination via the appropriate interface

within 24 hours of making the NF LOC determination. The information is processed by the

appropriate Income Support Division (ISD) office once received. The MCO also sends the NF

notification form to the NF with the NF LOC effective dates and prior authorization information.

o Once eligibility is established, the ISD office notifies the NF and the MCO.

o The NF must notify the PASRR Unit of the status of the resident’s eligibility.

o The MDS, which includes the Medicaid number and the certified length of stay, is completed by

the PASRR Unit.

o Upon completion, the MDS is submitted to the MCO/UR Contractor.

6.4. Level of Care Packet for Nursing Facilities

• PASRR

• NF LOC Notification Form - used for all prior approval reviews

o All requests for prior approval will be submitted on the NF LOC Notification Form.

o The NF should document what type of review is being requested at the top of the NF LOC

Notification Form:

▪ Initial;

▪ Continued Stay;

▪ Medicaid Pending;

▪ Transfer;

▪ Re-admit;

▪ Re-Review;

▪ Reconsideration; and/or

▪ All other required fields must be completed.

• MDS

o An MDS and all other appropriate documentation must be completed for each resident for

every situation requiring prior approval.

Section 6: Nursing Facilities

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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o All locator fields must be clearly marked on the MDS.

o When the resident goes from Medicare co-pay to Medicaid, the NF submits an Internal MDS

that begins the UR process for the resident.

o Appropriate documentation must accompany the MDS. Generally, appropriate documentation

includes a valid order and must:

▪ Be signed by a physician, nurse practitioner, clinical nurse specialist, or physician assistant;

▪ Be dated; and

▪ Indicate the LOC – either high NF (HNF) or low NF (LNF).

The NF must submit the initial NF LOC packet to the MCO no later than 30 calendar days after

admission, which includes all of the above documentation and the physician’s order. The MCO may

assign unexcused late days if the NF submits the LOC packet later than 30 calendar days. Please refer to

the Current/Retrospective Reviews Section above for more information about assignment of late days.

Once an order is signed and dated, it cannot be changed. If a change is required, a new order must be

written, signed, and dated by the physician, nurse practitioner or physician assistant.

Verbal or telephone orders are permitted. The order must be taken by an RN or LPN who must also sign

and date the order. It must be clearly indicated the order is a telephone or verbal order with the name

of the physician, nurse practitioner or physician assistant who gave the order and LOC. The date of the

call or verbal communication is the date of the order.

The MCO approves the documentation and makes a LOC determination following the New Mexico

Medicaid NF LOC Instructions and Criteria within five business days of receiving a completed packet. The

MCO shall review the documentation provided to determine the appropriate NF LOC and transmits the

determination via the appropriate interface file within 24 hours of making the NF LOC determination. A

packet that requests LNF but meets HNF criteria shall be upgraded to HNF; a packet that requests HNF

but only meets LNF criteria shall be downgraded to LNF. A new doctor’s order is not required.

When required documentation is missing, an RFI sheet will be generated by the MCO and sent to the NF.

If the required documentation is not provided to the MCO within 14 business days of the request, it will

be technically denied. The MCO will make three attempts during the 14-business day period to contact

the NF to obtain the information. The MCO will transmit a technical denial via the ASPEN interface file

within 24 hours of no response from the NF. Please see Current/Retrospective Reviews for more

information on assignment of late days.

Note: A formal RFI to the NF to justify the HNF request is not required when reviewing and processing

HNF requests that clearly do not meet HNF criteria but do meet LNF criteria or vice versa. In the event a

Section 6: Nursing Facilities

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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determination is upgraded or downgraded from the physician’s order the MCO shall assign the LOC and

provide the NF with technical assistance to educate the NF on determination criteria.

The MCO faxes the NF notification form with authorization and date spans to the NF.

Short-term skilled stays:

For short-term stays (90 days or less) the MCO will provide ISD with NF LOC determination dates but will

only issue a prior authorization to the NF for the authorized bed days, if appropriate and after eligibility

has been established.

The updated NF LOC criteria published on 01/ 01/2019 includes General Eligibility Requirements under

Section V. This section explains the minimum requirements for LOC and includes information on when

the MCO should not assign a LOC, but rather issue a skilled nursing authorization.

Not appropriate for NF care: The member’s needs are too complex or inappropriate for NF, such that:

• The member requires acute level of care for adequate diagnosis, monitoring and treatment or

requires inpatient based acute rehabilitation services.

▪ Members who reside in a NF long-term and have a clinical episode which

requires hospitalization, should be evaluated for skilled nursing services once

readmitted to the facility to determine if the member requires acute therapy

related to the hospitalization.

▪ Members who reside in a NF long-term and have a clinical episode which does

not require hospitalization, but may indicate a change in LOC, should be

evaluated for HNF.

▪ Members who do not reside in the NF but have been hospitalized and require

inpatient based acute rehabilitation services should be evaluated for skilled

nursing services.

6.5. Denial of Requests for NF LOC Determinations

If the NF LOC criteria is not met and the request for initial NF placement or Medicaid pending is denied,

the MCO will send the referring party and the applicant a denial letter within five business days of

receipt of a completed packet, with the reason for denial as determined by the MCO. The requesting

provider then has the opportunity to request a Re-review and/or Reconsideration of the MCO’s decision

per the timelines indicated in section 6.15. If no reconsideration is requested, the MCO will transmit the

determination via the ASPEN interface file within 24 hours of making the NF LOC determination. The

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applicant will receive a Notice of Case Action from the ISD office, which explains the right to request an

administrative hearing.

Providers who disagree with the initial review decision must request a Re-review of the decision(s)

before requesting a Reconsideration. Please see section 6.15 for timelines and requirements.

If the NF LOC criteria is not met for an existing resident, the MCO will send the referring NF and the

member a denial letter with information regarding the right to appeal to the MCO before requesting an

administrative hearing. The MCO will not transmit the denial via the ASPEN until a final appeal decision

has been made or until after the allowed time to request an appeal has lapsed, whichever is later.

6.6. Reserve Bed Days

Medicaid pays to hold or reserve a bed for a resident in an NF to allow for the residents to make a brief

home visit, for acclimation to a new environment or for hospitalization according to the limits and

conditions outlined below.

• Medicaid covers six reserve bed days per calendar year for every LTC resident for hospitalization

without prior approval. Medicaid covers three reserve bed days per calendar year for a brief home

visit without prior approval.

• Medicaid covers an additional six reserve bed days per calendar year with prior approval to enable

residents to adjust to a new environment, as part of the discharge plan.

o Resident’s discharge plan must clearly state the objectives, including how the home visits or

visits to alternative placement relate to discharge implementation.

o The prior approval request must include the resident’s name, Medicaid number, requested

approval dates, copy of the discharge plan, name and address for individuals who will care for

the resident during the visit or placement and a written physician order for trial placement.

Requests for additional discharge reserve bed days must be submitted by the NF to the MCO that the

resident is enrolled with for prior approval. The NF follows the written process of the MCO for

submission of the request, and receipt of documentation of the approval. The written process of the

MCOs must also indicate if any documentation or procedures are required of the NF to assure payment

of claims for approved discharge reserve bed days.

Section 6: Nursing Facilities

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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6.7. Initial Determination, Redetermination, and Pending Medicaid Eligibility

• Initial Determination: All services furnished by Medicaid NF providers must be medically necessary.

The procedures described in the NF Procedures for Requests for Prior Approval Section above,

should be referred to when preparing documents for all initial reviews. Documents must be

completed and submitted within 30 calendar days of admission.

Initial length of stays:

o Initial HNF is not to exceed thirty (30) days; however, a shorter length of stay can be

assigned based on the needs of the resident;

o Initial LNF cannot exceed ninety (90) days; however, a shorter length of stay can be assigned

based on the needs of the resident.

• Redetermination: The medical documentation must be faxed and received by the MCO a minimum

of 60 calendar days prior to the start date of the new certification period for LNF and 30 calendar

days prior for HNF.

Continued stay length of stays:

o HNF continued stay reviews can be certified by the MCO for up to 90 days based on the

medical needs and stability of the resident.

o LNF continued stay reviews can be certified by the MCO up to 365 days based on the

medical needs and stability of the resident.

Prior approval reviews are required for all requests for the continued stay of a resident in a NF.

These reviews are based on the medical necessity of NF services being continually provided to the

resident. The medical necessity decision is made during the continued stay review. Thirty days

before the expiration of the current certification, a request for continued stay must be received by

the MCO.

• Pending Medicaid Eligibility: Prior approval reviews can be done when the service is furnished

before the determination of the effective date of the resident’s financial eligibility for Medicaid. If

the resident is applying for Medicaid, both financial and medical eligibility at the same time, please

write “Medicaid Pending” in the type of request box on the Notification form. Note: A resident on

SSI is not considered Medicaid Pending.

o When an individual is admitted to a NF pending Medicaid financial eligibility, the NF submits

a completed Minimum Data Set (MDS) with required documentation and a Physician’s,

Nurse Practitioner’s or Physician Assistant’s order for LOC. The Notification Form - Section I.

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January 1, 2019; October 1, 2020

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Nursing Facility Prior Authorization Request - should have “MEDICAID PENDING” selected

for Type of Request (Choose an item from the drop-down menu).

o The MCO will review the information submitted and determine the NF LOC.

o The MCO will issue NF LOC, if appropriate but will only issue a prior authorization to the NF

for the authorized bed days, and after eligibility is established.

o The MCO will review the information submitted and determine the NF LOC.

o The Prior Authorization form will be completed by the MCO and sent to the NF.

o The MCO will transmit the NF LOC determination via the ASPEN interface within 24 hours of

making the determination.

6.8. Care Plan and Emergency Preparedness

Care Plan

The NF must develop a care plan, per 42 CFR 483.21, for each resident within 48 hours of admission, to

include instructions needed to provide effective and person-centered care that meets professional

standards of quality of care. The care plan must include all specialized or rehabilitation services the NF

will provide as a result of PASRR recommendations.

Emergency Preparedness

The NF must be in compliance with 42 CFR 483.73 including, but not limited to:

• Self-Assessment and Planning:

o Develop an emergency plan based on a risk assessment;

o Perform risk assessment using an “all-hazards” approach, focusing on capacities and capabilities;

and

o Update emergency plan at least annually.

• Policies and Procedures:

o Develop and implement policies and procedures based on the emergency plan and risk

assessment;

o Policies and procedures must address a range of issues including subsistence needs, evacuation

plans, procedures for sheltering in place, tracking patients and staff during an emergency; and

o Review and update policies and procedures at least annually.

• Communication Plan

o Develop a communication plan that complies with both Federal and State laws;

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o Coordinate patient care within the facility, across health care providers, and with State and local

public health departments and emergency management systems;

o Review and update plan annually; and

o Share information from the emergency plan with residents, family members or representatives,

and the member’s MCO.

• Training and Testing Requirements

o Develop and maintain training and testing programs, including initial training in policies and

procedures;

o Demonstrate knowledge of emergency procedures and provide training at least annually; and

o Conduct drills and exercises to test the emergency plan.

6.9. Retroactive Medicaid Eligibility

Written requests for prior approval based on a resident’s retroactive financial eligibility must be

reviewed by the MCO within 30 calendar days of the date of the eligibility determination. The NF must

submit all appropriate medical documentation to the MCO for the NF LOC determination. The MCO will

transmit the determination via the ASPEN interface file within 24 hours of making the NF LOC

determination. Requests for retroactive eligibility will not be accepted after 180 days of the Medicaid

eligibility determination date. Please see NMAC 8.281.600.13.

6.10. Re-Admission Reviews

When the resident leaves the NF for three or more midnights for an inpatient hospital stay, a

readmission review is required.

The NF must submit a re-admit MCO approval request form within 30 calendar days together with the

following accompanying documentation – the hospital discharge summary and/or resident’s admission

note back to the NF.

• When the resident is re-admitted to the NF and has more than 30 calendar days left on his/her

certification, days will be assigned from the re-admit date. The NF sends the notification form to the

MCO along with supporting documentation.

• If the resident has less than 30 calendar days left on his/her certification, the NF will not submit a

re-admit notification form. Instead the NF should submit a re-determination (annual or continued

stay) request on the notification form along with supporting documentation.

Section 6: Nursing Facilities

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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6.11. Current/Retrospective Reviews

Medical documentation for initial, redetermination, re-admit and changes in LOC reviews can be

reviewed retrospectively if requested by the NF.

A request for a current or a retrospective review for initial (including Medicaid pending),

redetermination or re-admit reviews will be considered; however, the below outlines the procedure for

unexcused and excused assignment of late days by the MCO.

Unexcused late reviews

Starting July 1, 2014, the NF may lose payment for each day that the NF LOC review is submitted late.

Excused Late Reviews

Prior authorization forms not submitted timely due to reasons beyond the control of the NF must be

submitted to the MCO with a detailed written explanation and documentation that supports the request

for an excusable late review. Reimbursement and retrospective reviews:

• If the reason for the delay in documentation submission was within the control of the NF, the

effective date for reimbursement is the date the packet was received by the MCO.

• Medicaid will not reimburse NFs for DOS not covered by the MCO prior authorization form. In

addition, the Medicaid member and his/her family member(s)cannot be billed for the services

provided by the NF. The NF will not discharge the resident due to assignment of late days by the

MCO.

6.12. Transfer from Another NF

If a resident transfers from one NF to another NF, the following procedures apply:

• The receiving NF must notify the MCO by telephone that a transfer to its NF is to occur. The

receiving NF will provide the MCO with the date of the transfer. Without this information, claims

submitted by the receiving NF will not be paid by the MCO.

o If there are more than 30 calendar days on the resident’s current authorization, the MCO will fax

the receiving NF the completed notification form which will include the prior authorization and

date span.

o If there are less than 30 calendar days remaining on the resident’s current authorization, the

receiving NF shall request a continued stay on the notification form to the MCO. The MCO shall

make a new NF LOC determination; the days remaining on the current certification will be added

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to the continued stay. Please write “Transfer” in the type of request box on the notification

form.

• The NF receiving the resident receives the status of resident’s reserve bed days from the MCO

through the notification form. This includes the number of days used during a calendar year and the

reason for the use of these days. This information is placed in the resident’s NF records.

6.13. Changes in the LOC

All changes in LOC require a new notification form that should be submitted within 30 calendar days of

the change in LOC. If a prior authorization form is being submitted for a change in LOC, please write

“LOC Change” in the type of request box on the notification form. The NF must provide a signed and

dated order from the physician, nurse practitioner or physician assistant as well as any documentation

to support the LOC request (see New Mexico NF LOC Instructions and Criteria). The date the LOC change

occurred must be clearly stated.

6.14. Discharge Status

Discharge status occurs when a resident no longer meets the LOC that qualifies for NF placement, but

there is no option for community placement at that time. Individuals are often already residing in an NF

at the time of initial application for Medicaid. In addition, Medicaid eligible individuals residing in an NF

may clinically improve to the point that they no longer meet an NF LOC. Such individuals may lack the

personal or family resources to provide for their own ongoing care in the community if discharged from

the NF. Community-based health care and support services may be limited or unavailable. Residents

may be at risk for failure to thrive outside the supportive structured environment of the NF. Physically

discharging the resident under such circumstances may put the resident’s health at risk.

To accommodate this health care issue, the New Mexico Medicaid program allows for temporary

continuation of coverage at LNF level of reimbursement while the NF and the MCO actively address the

development of community placement on an ongoing basis to meet the resident’s lower level of need.

The temporary continuation of coverage while discharge planning is taking place for a resident is termed

“Discharge Status;” however, Discharge Status does not mean the resident is being discharged from the

facility. Families and residents should not be told the resident is being discharged from the facility. The

MCO Care Coordinator, family, resident, and NF will work together to develop a transition plan to safely

transition the resident to an alternate SOC per Section 5 of this Manual.

Section 6: Nursing Facilities

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• Initial Discharge Status is authorized at LNF for a maximum of 90 calendar days, based upon the

MCO physician determination.

• Continued Stay Discharge Status is authorized at LNF for not less than 180 calendar days and up to

365 calendar days. Submission of a continued stay on a prior authorization form for a resident in

Discharge Status must acknowledge the resident’s Discharge Status and document the facility staff’s

and MCO Care Coordinator’s ongoing attempts to find and develop appropriate community

placement options for the resident. The facility should document why the resident must remain in

an NF environment if the resident is at risk for failure to thrive upon discharge to a community

placement. Failure to submit sufficient documentation specifying the facility’s discharge planning

efforts could result in the denial of prior authorization. The resident’s inability to afford assisted

living services may be a consideration in discharge planning.

6.15. Re-Review, Reconsideration, Appeal, Administrative Hearing

• Re-review: The Re-review must be requested within ten (10) calendar days after the date on

the written notification of the MCO decision or action. Requests for a Re-review must be

submitted in writing directly to the MCO. The MCO completes and submits a written Re-review

decision to the NF within six (6) business days from receipt and will include the decision and

information on the Reconsideration process. Providers who do not meet the ten (10) calendar

days for a Re-review may request a Reconsideration.

• Reconsideration: Providers who disagree with a Re-Review NF LOC determination can request

reconsideration. Members who disagree with a NF LOC determination may request the provider

to pursue reconsideration on his or her behalf. Requests for reconsideration must be in writing

and received by the MCO within thirty (30) calendar days after the date on the Re-Review

decision notice. The MCO completes and submits a written Reconsideration decision to the NF

within ten (10) business days of receipt and will include the decision and information on the

MCO Appeals and HSD Administrative Hearing process, as appropriate. The provider or eligible

recipient may file a written request for Reconsideration up to 14 calendar days past the 30-

calendar day limit if the MCO finds there was “good cause” for failure to file a timely request.

The provider or the eligible recipient is responsible for providing written documentation

supporting “good cause” for failure to file a timely request. “Good cause” includes a death in the

family, disabling personal illness, other significant emergency or executional circumstance.

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o The request for reconsideration must include the following:

▪ Statement that reconsideration is requested;

▪ Reference to the challenged decision or action;

▪ Basis for the challenge;

▪ Copies of any document(s) pertinent to the challenged decision or action; and

▪ Copies of claim form(s) if the challenge involves a claim for payment which is denied

due to a decision.

Individuals employed with the MCO, who were not participants in the initial decision, conduct

the Reconsideration review.

The MCO reviews the information and findings upon which the initial action was based, and any

additional information submitted to, or otherwise obtained by, the MCO. The information can

include the following:

• case records and other applicable documents submitted to the MCO by the provider

when the request for services was initially submitted;

• findings of the reviewer resulting in the initial decision;

• complete record of the service(s) provided, including hospital or medical records;

and

• additional documents submitted by the provider to support a Reconsideration

review.

The MCO performs the Reconsideration and furnishes the Reconsideration decision within ten

(10) business days of receipt of the Reconsideration request.

The MCO gives the provider and the eligible recipient written notice of the reconsideration

determination. If the decision is adverse to the eligible recipient the notice includes information

on the eligible recipient’s right to an MCO appeal, HSD Administrative Fair Hearings, timeframes

to file an appeal or fair hearing, and how to request continuation of benefits, as applicable.

• Appeal: If a reconsideration determination is adverse to the member, the member may request an

appeal with his or her MCO in accordance with 8.308.15 NMAC.

• State Administrative Fair Hearing: After the parties have exhausted the MCO appeals process, the

parties may request an administrative hearing according to State administrative rule 8.352.2 NMAC.

The MCO/UR Contractor is responsible for the development of the Summary of Evidence (SOE) to

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ISD and for the testimony of the NF LOC denial during the fair hearing, including denied NF LOCs for

Medicaid Pending residents.

6.16. Communication Forms

The MCO shall use the approved HSD forms at https://www.hsd.state.nm.us/providers/nursing-facility-

level-of-care.aspx for the updated forms for communication and notification with the NFs.

6.17. External Audits of NF LOC Determinations

HSD or its designee will audit a sample of each MCO’s NF LOC determinations to ensure the LOC criteria

are being appropriately applied by the MCOs. Each MCO will submit a universe of NF LOC

determinations to HSD or its designee for review. HSD or its designee will meet with the MCO to discuss

audit findings.

6.18. MCO Internal Audits of NF LOC Determinations

Each MCO will conduct internal random sample audits of both facility and CB NF LOC determinations

based on HSD NF LOC instructions and tool guidelines each quarter. The audit will include, at a

minimum: accuracy, timeliness, training documentation of reviewers, and consistency of reviewers. The

results and findings will be reported to HSD by the 7th day of the month following the end of the quarter

along with any Quality Performance Improvement Plan via DMZ (NF LOC reviews folder). The naming

convention for the results and findings file is MCO, quarter, year, internal audit results. For example, if

the MCO is submitting first quarter reviews, the file shall be named “MCO-name.Q1.18.internal audit

results.”

6.19. RESERVED

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7. Community Benefits

7.1. General Information

Community Benefits (CBs) are services that provide assistance to individuals who require LTSS so they

may remain in the family residence, in their own home, or in community residences. This program

serves as an alternative to placement in a NF. CB do not provide 24-hour care and are intended as a

supplement to an individual’s natural supports. CB services are available to members meeting a NF LOC.

The member’s MCO shall provide the CB services as determined appropriate by the CNA. Members

eligible for CBs have the option of selecting either the Agency-Based Community Benefit (ABCB) or

SDCB.

Two eligibility components must be met prior to receiving CB services: financial eligibility, determined by

the HSD/ISD and medical eligibility, determined by an MCO through a NF LOC assessment conducted as

part of the CNA. Additionally, if an individual is under the age of 65 and has not been deemed disabled

by the Social Security Administration (SSA), they must be evaluated by MAD’s Disability Determination

Unit (DDU) to establish their disability meets SSA guidelines. See NMAC 8.290.400.10(A).

Members who have a Full Medicaid COE may be eligible for CB if they meet an NF LOC and indicate they

have a need for CB. These individuals should request a CNA from their MCO to be assessed for CB. These

individuals do not need an allocation to access CB (see Section 5 Transitions of Care). Individuals up to

age 21 may be eligible for the EPSDT program, which provides personal care services (PCS). If a Medicaid

enrolled minor indicates he or she has a need for CB and meets an NF LOC, an allocation is not needed

to access CB services.

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7.2. Definitions

1. Active Registration: A registration is active if there is an open category of registration on the Central

Registry.

2. Activity of Daily Living (ADL): Tasks that are essential for self-care, such as bathing, feeding oneself,

dressing, toileting and transferring.

3. Agency Based Community Benefits (ABCB): The CB services offered through a provider agency to a

member who does not wish to self-direct his or her CB services.

4. Allocation: The opportunity given to a registrant who is NOME to apply for CBs.

5. Allocation Packet: The documents sent by HSD/MAD/LTSSB to a registrant that includes the Letter

of Interest (LOI), Primary Freedom of Choice (PFOC), Withdrawal Form, Medicaid Application for

Assistance, and a self-addressed stamped envelope.

6. Central Registry: A database that maintains a list of individuals who are interested in receiving CBs

and may be eligible for an allocation.

7. Community Benefits (CB): HCBS that provide LTSS to eligible members that allow them to remain in

the family residence, in their own home, or in community residences such as an Assisted Living

Facility.

8. HSD 100: “Medicaid Application for Assistance” that is used to apply for CBs and is available online

or at a local HSD/ISD office.

9. Inactive Registration: A registration is inactivated/closed under certain circumstances (see

Section 7.10 of this Manual, Closing/Inactivating an Allocation).

10. Letter of Interest (LOI): The letter that is sent to a registrant informing him or her that an allocation

is available and that he or she may apply for CBs.

11. Notice of Allocation (NOA): The letter that is sent to a registrant informing him or her that the PFOC

was received at HSD/MAD/LTSSB and informs him or her of the next steps in the allocation process.

The date of the NOA is the allocation date.

12. Nursing Facility Level of Care (NF LOC): The member's functional level is such that two or more ADLs

cannot be accomplished without consistent, ongoing, daily provision, of some or all of the following

levels of service: skilled, intermediate or assistance. A member must meet an NF LOC to be eligible

for CB services.

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13. Primary Freedom of Choice (PFOC): The form included in the Allocation Packet that allows a

registrant to confirm his or her interest in pursuing the opportunity to apply for CB services.

14. Self-Directed Community Benefits (SDCB): CB services offered to a member who is able to and who

chooses to self-direct his or her CB services.

15. Withdrawal Form: The form that is contained in the Allocation Packet that allows a registrant to

withdraw his or her request to apply for CB services.

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7.3. Nursing Facility Level of Care

NF LOC determinations for CB members:

All individuals receiving CB services must meet NF LOC eligibility requirements initially and annually

thereafter, unless eligible for continuous NF LOC.

Members who have a full Medicaid COE do not need an allocation to access CB. The member must

contact his/her MCO Care Coordinator to request an NF LOC evaluation to determine if medical

eligibility can be established. The Care Coordinator must schedule a CNA, to be completed in the

member’s home. The CNA must be scheduled within 30 calendar days of the member’s request for CB

services.

Once medical eligibility is established, the member must be reevaluated for NF LOC eligibility annually.

The MCO Care Coordinator must begin the NF LOC evaluation process (i.e., schedule the CNA) 120

calendar days prior to the existing NF LOC expiration date. The MCO must send 120 and 60 calendar day

reminder letters to the member. If the member has not complied with the CNA process and there are

only 30 calendar days left before the NF LOC expiration date, the MCO will send a Notice of Action to

the member explaining that CB services will expire in 30 calendar days due to member not complying

with the NF LOC evaluation process. The NOA must advise the member that if CB services are desired,

the CNA process must be completed. The notice must include member appeal and fair hearing rights.

Individuals requesting CB services who are not eligible for a full Medicaid COE, must place their name on

the Central Registry as described later in this section of the Manual.

7.4. Continuous NF LOC for Certain Eligible Members

CB members who meet the following criteria may be eligible for a continuous NF LOC. The MCO is

required to complete the CNA as outlined in Section 4 of the Manual.

• The member must have had an approved NF LOC for the prior three years.

• The approved NF LOC must be related to the member’s primary diagnosis.

• A continuous NF LOC status must be approved initially and annually by the MCO Medical Director

and documented in the member’s file.

• The member’s PCP must annually complete and sign a form that documents the member’s ongoing

ADL deficits related to the member’s primary diagnosis. The MCO must maintain this form in the

member’s file.

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• The MCOs will be required to regularly report to HSD the number of members with approved

continuing NF LOC status and other related information.

Conditions that may warrant a continuous NF LOC include, but are not limited to:

• Cerebral Palsy;

• Chronic Obstructive Pulmonary Disease (end stage);

• Cystic Fibrosis;

• Dementias (such as Alzheimer’s, Multi-Infarct, Lewy Body);

• Developmental Disability (such as microcephaly and severe chromosomal abnormalities);

• Neurodegenerative Diseases (such as ALS, muscular dystrophy, multiple sclerosis,);

• Paralysis secondary to Cerebral Vascular Accident;

• Parkinson’s Disease;

• Paraplegia;

• Quadriplegia;

• Spina Bifida;

• Paralysis secondary to severe spinal cord injury; or

• Ventilator Dependent.

7.5. External Audits of NF LOC Determinations

HSD or its designee will audit a sample of each MCO’s NF LOC determinations to ensure the LOC criteria

are being appropriately applied by the MCOs. Each MCO will submit a universe of NF LOC

determinations to HSD or its designee for review. HSD or its designee will meet with the MCO to discuss

audit findings.

7.6. MCO Internal Audits of NF LOC Determinations

Each MCO will conduct internal random sample audits of both facility and CB NF LOC determinations

based on HSD NF LOC instructions and tool guidelines each quarter. The audit will include, at a

minimum: accuracy, timeliness, training documentation of reviewers, and consistency of reviewers. The

results and findings will be reported to HSD by the 7th day of the month following the end of the quarter

along with any Quality Performance Improvement Plan via DMZ (NF LOC reviews folder). The naming

convention for the results and findings file is MCO, quarter, year, internal audit results. For example, if

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the MCO is submitting first quarter reviews, the file shall be named “MCO-name.Q1.18.internal audit

results.”

7.7. Registration for the CB for NOME Members

The ALTSD/ADRC (referred to as ADRC from this point forward) manages the Centennial Care Central

Registry by enrolling individuals, completing the pre-assessment, assigning the category of registration,

and sending Exception requests to HSD/MAD/LTSSB. Any individual has the right to place his or her

name on the Central Registry if: it has been determined the individual is not currently Medicaid eligible,

or current Medicaid shows a termination date, or the individual has applied for Medicaid and received a

denial.

At the time of registration, if the individual has a Medicaid COE entitling the individual to full Medicaid

benefits, the ADRC shall refer the individual to his or her MCO.

Any individual has the right to register for multiple waivers at the same time. Individuals may place their

name on the Central Registry by calling or appearing in person at the ADRC. An individual must be a

resident of the state of New Mexico in order to be registered. Residency is determined based on the

State’s eligibility rule for Medicaid. It is the individual’s responsibility to inform the ADRC of any changes

in address and/or telephone number so the Central Registry can be updated. Individuals are also

encouraged to contact the ADRC if they have significant changes in their health condition or living

situation. These circumstances may affect their type of registration.

Individuals should note that the Central Registry records information such as: the applicant’s

demographic information, the date of registration, and the applicant’s specific LTC needs. Individuals are

also required to complete a pre-assessment which aids the ADRC staff in directing the applicant to the

appropriate category of registration: Community Reintegration, Expedite, and Regular. The registration

types are defined as follows:

• Community Reintegration – provides individuals the opportunity to move out of an NF and back

into the community for a registrant who is residing in an NF at the time of registration. In order to

be eligible for CRI, the registrant must have resided in an NF for 90 consecutive days. Within the 90

consecutive days, the registrant may have been hospitalized and returned to the NF for the

remainder of the 90 days. If the 90-day stay was confined to only a hospital stay and the client was

never in a NF this does not qualify them for a CRI, they would have to be evaluated under another

allocation type such as Regular or Exception. The individual participating in the community

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reintegration process must be capable of comprehending the decisions being made or have a

primary caregiver or legal guardian that understands the options. The individual must not require

ABCB services 24 hours per day in his or her home. The intent of CRI is to assist the individual to

become integrated into his/her community and be as independent as possible. The MCO must be

able to ensure a reasonable level of health and safety for the member while ABCB services are being

provided. ABCB services must be cost-effective and must not exceed the average annual per capita

costs of NF services as determined by HSD.

CRI registration for the ABCB can be completed by calling the ADRC. Once a continuous 90-day stay

is confirmed by the HSD/MAD/LTSSB and funding is available, a community re-integration allocation

is granted. The HSD/MAD/LTSSB sends the allocation packet to the registrant/representative. The

allocation paperwork must be returned to the HSD/MAD/LTSSB within 45 calendar days or the

allocation will be closed, and the registrant will need to re-register for placement on the Central

Registry and wait for another allocation. If an extension is needed to complete the packet,

HSD/MAD/LTSSB must be notified to grant the extension (see “The Allocation Process: Timelines for

the Allocation Packet”).

Once the PFOC and HSD 100 are received by HSD/MAD/LTSSB, the allocation is processed (see “The

Allocation Process: Processing PFOCs”). Once the allocation has been granted, it is the MCO’s

responsibility to ensure services are authorized and in place prior to discharge to ensure a safe and

appropriate discharge.

The MCO must contact the registrant within five business days of receipt of the PFOC to schedule an

initial assessment to determine medical eligibility. The assessor explains the CRI process to the

registrant/representative. If the registrant/representative wishes to remain in the institution, the

Withdrawal Form must be completed, signed and mailed to HSD/MAD/LTSSB. If the

registrant/representative wishes to proceed with the eligibility process, the MCO proceeds with the

medical eligibility process.

• Expedite (EXP) – a registrant who has an urgent need for care. To be eligible, the registrant must:

o Be pre-assessed by the ADRC to require total assistance in at least three categories of ADLs; and

o Score a minimum of 48 points on the ADRC pre-assessment.

• Regular (REG) – a registrant who does not meet the criteria for any of the other registration types,

based upon the ADRC pre-assessment.

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Individuals may request an Exception to their category of registration and request an Expedited

allocation to the ADRC, under extreme circumstances. The ADRC will send the request to the

HSD/MAD/LTSSB who will consider issuing an Expedited allocation. The following are examples of

circumstances that may warrant an Exception request for an Expedited allocation:

o To ensure continuity of care, an individual was receiving CBs under a full Medicaid category of

assistance and his or her full Medicaid eligibility terminated. An individual must inform the ADRC

that he or she has lost full Medicaid and was receiving CBs. The request must be made to ADRC

within six months of termination of the full Medicaid category of assistance;

o An individual who was in an NF for 90 consecutive calendar days and was not registered for a

CRI allocation prior to discharge. The request must be made to ADRC within 30 calendar days

after discharge from the NF;

o An individual is residing in a Medicaid approved Assisted Living Facility, has been paying out of

pocket, and can no longer afford the private pay;

o An individual who has been diagnosed as having Acquired Immunodeficiency Syndrome (AIDS)

or Aids-Related Complex (ARC);

o An individual who no longer qualifies for the MFW and is ventilator dependent; or

o In rare cases, an individual with an extreme health and safety risk.

7.8. Allocation Process

The ADRC manages the Central Registry by enrolling individuals, completing the pre-assessment, and

sending Exception requests to HSD/MAD. The HSD/MAD/LTSSB manages the allocation process by

mailing Allocation Packets to registrants and forwarding completed allocation paperwork to HSD/ISD

and to the MCO. In order to facilitate the allocation process, the ADRC shall:

• Maintain accurate registrant information in the Central Registry, including coding of category of

registration for each registrant; and

• Change a registrant’s category of registration, if the ADRC obtains information that justifies the

change (e.g., a registrant leaves an NF before the 90-day requirement is met).

When the HSD/MAD Director determines a regular allocation should be released, the allocation process

begins by sending the Allocation Packet to the registrant. The registrant is notified there is an allocation

available and is asked to respond by returning a completed PFOC and HSD 100, or a Withdrawal Form.

The Allocation Packet contains the following:

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• LOI;

• PFOC;

• Withdrawal Form;

• HSD 100 “Medicaid Application for Assistance”;

• CBs Informational Brochure; and

• Business Reply envelope addressed to HSD/MAD/LTSSB.

Timeframes for the Allocation Packet:

• The registrant has 45 calendar days to return either a completed PFOC and HSD 100, or a

Withdrawal Form to HSD/MAD/LTSSB.

• The registrant may request a one-time extension to return the PFOC and HSD 100, or Withdrawal

Form by contacting the HSD/MAD/LTSSB, and if requested, it shall be granted for up to 30 calendar

days. Any additional time (extensions) requested by the registrant must be made directly to

HSD/MAD/LTSSB for approval.

• If there is no response to the Allocation Packet either after the original 45 calendar days or after the

expiration of any granted extensions, HSD/MAD/LTSSB shall send a closure letter to the registrant’s

mailing address on file.

Processing PFOCs:

Once HSD/MAD/LTSSB receives the PFOC and the HSD 100, HSD/MAD/LTSSB will review the documents

to ensure they are complete and signed by the registrant.

• If the PFOC is not complete and/or signed, the PFOC will be returned to the registrant, identifying

the information required, and providing the registrant up to 30 calendar days to complete and

return the form. Failure to return the PFOC within the 30-calendar days will result in closure upon

the 45th day, as described herein.

• If the PFOC and HSD 100 are completed and signed, HSD/MAD/LTSSB will process them by sending:

o A NOA letter to the registrant;

o A copy of the NOA, PFOC, and HSD 100 to the HSD/ISD Eligibility system; and

o A copy of the PFOC to the registrant’s MCO.

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7.9. Eligibility

Once the PFOC and HSD 100 have been distributed to HSD/ISD and the MCO, HSD/MAD/LTSSB’s

“Processing PFOCs” is complete. HSD/MAD/LTSSB is unable to assist with medical or financial eligibility.

Registrants must meet two types of eligibility, initially and annually, to receive and continue receiving

CBs:

• Medical Eligibility: The medical eligibility determination is completed by the MCO. In order to be

medically eligible, the registrant must meet an NF LOC. In addition, the CNA must indicate that the

registrant has a need for CBs.

o The MCOs must have established procedures for their call centers to resolve issues and address

inquiries from those who are allocated, but not yet fully enrolled with the MCO, because the

NFLOC determination has not yet been completed. The MCO must be able to identify these

individuals in their systems within two (2) business days of receipt of the PFOC or 112 trigger

and be able to address questions and concerns from these future members who are newly

allocated and may be enrolled in the MCO when eligibility is complete.

o The NF LOC shall be determined and transmitted to ASPEN within 40 calendar days from the

MCO’s receipt of the PFOC.

o The MCO shall submit the NF LOC determination to HSD/ISD, via the interface file, within 5

business days of the NF LOC determination so it can be used by HSD/ISD to complete the

eligibility process.

o If there is an existing NF LOC determination, the MCO shall submit the NF LOC effective dates to

HSD/ISD, via the interface file, within 5 business days of the MCO’s receipt of the PFOC so it can

be used by HSD/ISD to complete the eligibility process. A new NF LOC does not need to be

determined by the MCO, unless there are less than 120 calendar days remaining on the existing

NF LOC.

o The MCO shall submit the NF LOC effective dates and applicable SOC of ADB (Agency Directed

Services) to the Omnicaid system, via the interface file, within 5 business days of receiving the

member’s initial enrollment on the Enrollment Roster file.

o If an individual is under the age of 65 and has not been deemed disabled by the Social Security

Administration (SSA), they must be evaluated by MAD’s Disability Determination Unit to

establish whether they meet the disability criteria according to SSA guidelines. Current medical

records regarding the individual’s disability must be provided to ISD.

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• Financial Eligibility: In order to be financially eligible, income and assets must be below the

Institutional Care Medicaid (ICM)/Waiver maximum allowable amount. In addition, all other

financial and non-financial eligibility requirements must be met as determined by HSD/ISD.

Once eligibility is approved by HSD/ISD, the registrant’s ABCB services will be provided based on the CNA

conducted by the member’s MCO. Although the COE for the CB Waiver is approved, CB services will not

begin until the CCP is in place. CB services are not approved retroactively.

The member must participate in the ABCB service delivery model for a minimum of 120 calendar days

before the member requests a switch to the SDCB service delivery model. A member must contact their

MCO Care Coordinator to discuss the switch from ABCB to SDCB. The CB services are described in

Sections 8 and 9 of the Manual.

7.10. Closing/Inactivating an Allocation

An allocation will be inactivated by HSD/MAD/LTSSB if one of the following occurs:

• The registrant returns a signed Withdrawal Form;

• The registrant does not return the PFOC within the required timeframes;

• The ADRC or HSD/MAD/LTSSB is informed the registrant intends to remain in the NF;

• The ADRC or HSD/MAD/LTSSB is informed the registrant is no longer a resident of the State of New

Mexico;

• The ADRC or HSD/MAD/LTSSB has been notified the registrant has expired;

• The Allocation Packet is returned as undeliverable and no other contact information is available; or

• The registrant has a full Medicaid category of eligibility (COE) and has access to CB services through

their MCO.

7.11. Registrant Notice Requirements

The registrant is notified by letter in the following circumstances:

• New registration (mailed by the ADRC);

• When the State is unable to contact the registrant by telephone;

• When an allocation becomes available for the registrant (Allocation Packet);

• When an allocation is complete (NOA);

• When a registration is closed/inactivated for any reason other than a completed allocation; and

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• When the State has been notified that the registrant is deceased, a letter will not be sent to the

registrant or the registrant’s representative.

7.12. Undeliverable Notice

It is the registrant’s responsibility to inform the ADRC of any change in address and/or telephone

number. If a letter is returned to the State as undeliverable, HSD/MAD/LTSSB shall review the

registrant’s record to determine an alternate address and attempt to call the registrant or the

registrant’s representative to verify a correct mailing address. If HSD/MAD/LTSSB cannot obtain the

registrant’s address, the registrant’s Central Registry record will be inactivated due to the inability to

contact the registrant. HSD/MAD/LTSSB shall document the reason the registration has closed, the

specific attempts made to contact the registrant, and the date(s) of attempts, in the registrant’s journal

notes in the Central Registry.

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8. Agency-Based Community Benefits (ABCB)

8.1. General Information

The ABCB is intended to provide a community-based alternative to institutional care.

Members selecting the Agency-Based model have the choice of the consumer delegated or consumer

directed models for PCS.

HCBS shall meet the following requirements:

• Are integrated and support full access of members receiving Medicaid HCBS to the greater

community, including opportunities to seek employment, and work in competitive integrated

settings, engage in community life, control personal resources, and receive services in the

community, to the same degree of access as individuals not receiving Medicaid HCBS;

• Are selected by the member from among setting options including non-disability specific settings.

The setting options are identified and documented in the person-centered care plan and are based

on the member’s needs and preferences;

• Ensure a member’s rights of privacy, dignity and respect, and freedom from coercion and restraint;

• Optimize, but do not regiment, member’s initiative, autonomy, and independence in making life

choices, including but not limited to, daily activities, physical environment, and with whom to

interact; and

• Facilitate member choice regarding services and supports, and who provides them.

HSD will take the following factors into account when determining whether a setting may have the

effect of isolating members receiving Medicaid HCBS from the broader community of members not

receiving HCBS:

o Due to the design or model of service provision in the setting, members have limited, if any,

opportunities for interaction in and with the broader community, including with individuals

not receiving Medicaid funded HCBS. Opportunities as well as identified supports to provide

access to and participation in the broader community, should be reflected in both the

member’s person-centered care plans and policies and practices of the provider setting in

accordance with 42 CFR 441.301(c)(1)(3) and (4)(vi)(F), 42 CFR 441.530(a)(1)(vi)(F) and

441.540, and 42 CFR 441.710(a)(1)(vi)(F) and 441.725;

o The setting restricts member choice to receive services or to engage in activities outside of

the setting; or

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o The setting is physically located separate and apart from the broader community and does

not facilitate member opportunity to access the broader community and participate in

community services, consistent with the member’s person-centered care plan.

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8.2. Definitions

1. Adult: Individuals who are 21 years of age or older.

2. Allocation: Funding becomes available to serve additional individuals on the 1115 waiver who are

NOME.

3. Annual: The 12-month period covered by a Comprehensive Care Plan, except where otherwise

stated.

4. Adult Protective Services Division (APS): APS Division of the Aging and Long-Term Services

Department.

5. Care Coordinator (CC): The individual responsible for coordinating a member’s services in the

managed care program.

6. Child: An individual under 21 years of age.

7. Community Re-integration: Provides individuals the opportunity to move out of a SNF into a

community placement, after a 90-day continuous stay.

8. Comprehensive Care Plan (CCP): means a comprehensive plan of services that meets the

member’s physical, behavioral and long-term needs.

9. Electronic Visit Verification (EVV): EVV is a computer-based system that electronically verifies the

occurrence of authorized personal care service visits by electronically documenting the precise time

and location where a service delivery visit begins and ends.

10. Face-to-Face: Being in the physical presence of the individual who is receiving services.

11. Human Services Department (HSD): Designated by CMS as the Medicaid administering agency in

New Mexico. HSD is also responsible for operating the ABCB Services for populations that meet the

NF LOC.

12. Interdisciplinary Team (IDT): IDT, consisting of the member, the legal AR, the family, service

providers and other people invited by the member and the legal authority representative, if

applicable.

13. Immediate Family Member: Father (includes natural or adoptive father, father-in-law, stepparent),

mother (includes natural or adoptive mother, mother-in-law, stepparent), brother (includes

half-brother, step-brother), sister (includes half-sister, step-sister), son or daughter, step-son or step

daughter, adoptive son or daughter, natural grandfather, and natural grandmother and spouse

relationship to the individual.

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14. Incident Report: Required form for documenting all reportable incidents of abuse, neglect,

exploitation, death, expected and unexpected, environmental hazard, law enforcement intervention

and emergency services.

15. Medical Assistance Division (MAD): The MAD, New Mexico Human Services Department.

16. Natural Supports: Supports not paid for with Medicaid funds that assist the individual to attain the

goals as identified on the Comprehensive Care Plan. Individuals who provide natural supports are

not paid staff members of a service provider, but they may be planned, facilitated, or coordinated in

partnership with a provider.

17. Nursing Facility Level of Care (NF LOC): The member’s functional level is such that two or more ADL

cannot be accomplished without consistent, ongoing, daily provision, of some or all of the following

levels of service: skilled, intermediate or assisted. A member must meet an NF LOC to be eligible for

NF placement and CB services.

18. Parent: Natural or adoptive mother or father, or step-mother, step-father.

19. Person-Centered Care Plan (PCCP): A procedural plan that describes the provision of specified

activities and oversight on a routine basis in order to safeguard the health of the member.

20. Primary Caregiver: The person who takes primary responsibility for someone who cannot care-fully

for himself or herself. The primary caregiver may be a family member, a trained professional or

another individual.

21. Relatives: Immediate family members such as the parent of an adult, a sibling, grandparent, aunt,

uncle, etc. but not the parent of a minor child or a spouse.

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8.3. ABCB Services Requirements

These requirements apply to the services provided through the Medicaid 1115 Waiver for members who

meet the eligibility criteria for HCBS, ABCB. These requirements clarify, interpret, and further enforce

8.308.12 NMAC, Managed Care Program, Community Benefit.

• ABCB providers must meet all Federal requirements for HCBS providers, including the Final HCBS

Settings Rule. All ABCB providers must be enrolled as an active Medicaid approved provider

type 363 (Community Benefit Provider) and have HSD/MAD approval to provide that service. All

incomplete applications submitted to the HSD/MAD Long-Term Services and Supports Bureau

(LTSSB) shall be rejected and not considered for review until a complete application is

submitted.

The requirements address each service covered by the ABCB. Members served through this program will

expect to receive services that meet these requirements. Centennial Care MCOs must contract with an

active ABCB Medicaid approved provider type 363 that has approval from HSD/MAD to provide that

service before rendering CBs to members. Eligible ABCB providers are those that have been approved

and certified by the HSD/MAD/LTSSB, per 8.308.2.9 NMAC Managed Care Program, Provider Network.

Each MCO must ensure that it has an adequate statewide provider network for all ABCB Services.

These requirements define the services offered as approved by CMS. The ABCB services are supplement

to the member’s natural supports and are not intended to replace family supports. The ABCB is not a

24-hour service. The services are designed to increase independence and achieve personal goals while

providing care and support to enable individuals to live as active members of the community while

ensuring their health and safety. The purpose of this program is to provide assistance to individuals that

require LTSS so they may remain in the family residence, in their own home, or in community

residences. This program serves as an alternative to placement in an NF. The ABCB services are

implemented in accordance with the Person-Centered Care Plan (PCCP) and/or Comprehensive Care

Plan (CCP) as developed by the member and the MCO Care Coordinator. The PCCP must revolve around

the ABCB member and reflect his/her chosen lifestyle, cultural, functional, and social needs for

successful community living.

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8.4. ABCB Covered Services

All ABCB services are subject to the approval of the MCO/UR. Below is a list of ABCB covered services for

members in ABCB, followed by detailed service descriptions:

• Adult Day Health;

• Assisted Living;

• Behavior Support Consultation;

• Community Transition Services;

• Emergency Response;

• Employment Supports;

• Environmental Modifications;

• Home Health Aide;

• Nutritional Counseling;

• Personal Care – Consumer Directed;

• Personal Care – Consumer Delegated;

• Private Duty Nursing (PDN);

• Nursing Respite;

• Respite; and

• Skilled Maintenance Therapy Services.

o Occupational Therapy for Adults

o Physical Therapy for Adults

o Speech Therapy for Adults

8.5. Adult Day Health Services

Adult Day Health Services provide structured therapeutic, social and rehabilitative services designed to

meet the specific needs and interests of ABCB members as determined by the PCCP incorporated into

the CCP. Adult Day Health settings must be integrated and support full access of members receiving

Medicaid HCBS to the greater community, engage in community life, control personal resources, and

receive services in the community, to the same degree of access as individuals not receiving Medicaid

HCBS. The services are generally provided for two or more hours per day on a regularly scheduled basis,

for one or more days per week, by a licensed Adult Day Care Center, that offers health and social

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services to assist members to achieve optimal functioning. Meals provided as part of this service shall

not constitute a “full nutritional regime” (3 meals per day). Transportation to and from the Adult Day

Care Center must be coordinated by the Adult Day Care provider.

PDN services and Skilled Maintenance Therapies (physical, occupational, and speech) may be provided

in conjunction with Adult Day Health services, by the Adult Day Care provider or by another qualified

provider. PDN and therapy services must be provided by licensed nurses and therapists. The PDN and

Skilled Maintenance Therapies must be provided in a private setting at the facility.

Scope of Services/Requirements:

• The health, safety, and welfare of the member must be the primary concern of all activities and

services provided. Provider staff must supervise all activities. Activities provided by the Adult Day

Care Center are included in the negotiated rate with the MCO and are not billed separately. Specific

services may include the following:

o Coordination of transportation to and from the Adult Day Care center;

o Activities that promote personal growth;

o Activities that enhance the member’s self-esteem by providing opportunities to learn new skills

and adaptive behaviors;

o Supervision of self-administrated medication as determined by the New Mexico Nurse Practice

Act;

o Activities that improve capacity for independent functioning;

o Activities that provide for group interaction in social and instructional programs and therapeutic

activities;

o Personal Care Services (PCS);

o Meals that do not constitute a “full nutritional regime” of three (3) meals per day;

o Intergenerational experiences;

o Involvement in the greater community; and

o Providing access to community resources as needed.

• Activities shall be planned by the member, family, caregivers, volunteers, staff and other interested

individuals and groups. The provider must ensure safe and healthy conditions for activities inside or

outside the facility.

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• An IDT meeting for each member will occur at least quarterly to review ongoing progress of direct

services and activities. The PCCP will be adjusted as necessary to meet the needs of the member at

the quarterly meeting or at other times as needed. A PCCP will be developed with identified goals

and measurable objectives. It will be attached to or incorporated into the CCP.

• All activities must be supervised by provider staff. Members must never be left unattended. Adult

Day Care Center staff must be physically present with the member(s) at all times.

• Activities must be designed to meet the needs of the member and enhance the member’s

self-esteem by providing opportunities to:

o Learn new skills and adaptive behaviors;

o Improve or maintain the capacity for independent functioning; and

o Provide for group interaction in social and instruction programs and therapeutic activities.

Provider Requirements/Qualifications:

• Adult day health services may be provided by eligible adult day care agencies.

• Adult Day Care Centers must maintain (no gaps in licensure) a full permanent license by Department

of Health (DOH) as an adult day care facility pursuant to 7 NMAC 13.2. Adult day health facilities must

meet all requirements and regulations set forth by DOH as an adult day care facility pursuant to 7

NMAC 13.2. Provisional licenses will not be accepted.

• Adult Day Care Centers must comply with the provisions of Title II and III of the American’s with

Disabilities Act (ADA) of 1990, P.L. 101-336 (42 U.S.C. Section 12101, et seq.).

• In order to be approved and certified by the HSD/MAD/LTSSB Adult Day Care Centers must be

operating with a permanent license. All incomplete applications submitted to the HSD/MAD/LTSSB

shall be rejected and not considered for review until a complete application is submitted.

• Adult Day Care Centers must comply with all applicable cities, county or state regulations governing

transportation services, if providing transportation services to its members.

• Adult Day Care Centers must comply with the HSD/MAD requirements including but not limited to:

OSHA training requirements; incident management reporting; criminal background check (CBC); labor

laws, etc.

• Adult Day Care Centers must make appropriate provisions to meet the needs of adults who require

special services as indicated in the member’s Care Plans.

• The MCO will provide a copy of the CCP to the Adult Day Care Services Provider.

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• A written Adult Day Health Services PCCP will include the assessment of the special needs, the

interventions to meet those needs, and evaluation of the plan, with changes as needed. The PCCP will

be provided to the MCO Care Coordinator and must be incorporated into the member’s CCP.

• The provider must be culturally sensitive to the needs and preferences of the member.

Communicating in a language other than English may be required.

Reimbursement

Billing is on an hourly basis and is accrued to the nearest quarter of an hour. Training on

member-specific issues is reimbursable and included in the MCO negotiated hourly rate. General

training requirements are an administrative cost and not billable. Reimbursement for adult day health

services will be based on the negotiated rate with the MCO. Providers of this service have the

responsibility to review the prior authorizations issued from the MCO to ensure the information on the

prior authorization for their services is correct. If the provider identifies an error, they will contact the

MCO immediately to have the error corrected.

Limits or Exclusions

The member must attend the Adult Day Care Center for a minimum of two hours per day for one or

more days per week and the frequency (number of days per week) of attendance at the center must be

included in the individual’s PCCP and the CCP.

8.6. Assisted Living Facility (ALF)

Assisted living facilities offer residential services that provide a homelike environment which may be in a

group setting with individualized services designed to respond to the member’s needs as identified by

the member, provider and the Care Coordinator. A PCCP is developed with the member that needs

services in the ALF and incorporated in the CCP. Assisted living services include assistance with Activities

of Daily Living (ADLs) (i.e., ability to perform tasks that are essential for self-care, such as bathing,

feeding oneself, dressing, toileting, and transferring) and assistance with Instrumental Activities of Daily

Living (IADLs) (i.e., ability to care for household and social tasks to meet individual needs within the

community). Assisted living is based on the following fundamental principles of practice:

• Offering quality care that is personalized for the member’s needs;

• Fostering independence for each member;

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• Treating each member with dignity and respect;

• Promoting the individuality of each member;

• Allowing each member choice in care and lifestyle;

• Protecting each member’s right to privacy;

• Nurturing the spirit of each member;

• Involving family and friends in care planning and implementation;

• Providing a safe residential environment; and

• Providing safe community outings or activities.

Scope of Services/Requirements:

• Core services provide assistance to the member in meeting a broad range of activities of daily living.

Specific services may include the following:

o Personal Hygiene;

o Dressing;

o Eating;

o Socialization;

o Opportunities for individual and group interaction;

o Housekeeping;

o Laundry;

o Transportation;

o Meal preparation and dining;

o 24-hour, on-site response capability to meet scheduled or unpredictable member needs;

o Capacity to provide on-going supervision of the ABCB member within a 24-hour period;

o Coordination of access to services not provided directly;

o Participation in the IDT meetings for development of the PCCP;

o Implementation of the PCCP to meet the member’s needs, evaluation for effectiveness, and

adaptation as needs change;

o Services provided to a resident at an ALF are pursuant to the PCCP, developed by the member,

provider and the MCO Care Coordinator; and/or

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o Other direct services (not listed above as core services) that provide assistance to the member

in meeting a broad range of ADLs. Direct services may be provided by the ALF or may be

provided by another ABCB active, Medicaid approved type 363 provider with HSD/MAD

approval to provide that service. These direct care providers must be identified on the

member’s PCCP, that is separate from the CCP, and might include:

▪ PDN services for Adults (see the Scope of Services/Requirements for PDN); and/or

▪ Skilled Maintenance Therapies for Adults (see the Scope of Services/Requirements for

Skilled Maintenance Therapies).

Provider Requirements/Qualifications:

• Assisted Living Services must be provided by an active, Medicaid approved provider type 363

Assisted Living Facility (ALF).

• ALF must maintain (no gaps in licensure) a full permanent license by Licensing and Certification

Bureau, Division of Health Improvement/Department of Health. Provisional licenses will not be

accepted.

• ALF must comply with the provisions of Title II and III of the ADA of 1990, P.L. 101-336 (42 U.S.C.

Section 12101, et seq.).

• The ALF must be located in the State of New Mexico.

• In order to be approved and certified by the HSD/MAD/LTSSB, ALF must be holding and operating

with a fully approved permanent license. All incomplete applications submitted to the

HSD/MAD/LTSSB shall be rejected and not considered for review until a complete application is

submitted.

• Assisted Living providers must ensure that personnel providing direct services (directly employed by

the ALF or through a contract for services) meet all requirements established by HSD/MAD for direct

services such as, PDN, and skilled maintenance therapies (see Provider Requirements/Qualifications

for each separate service).

• Assisted Living providers are required to maintain staffing ratios and patterns that will meet the

member’s needs as identified in the PCCP and the CCP.

• Assisted Living providers will develop a PCCP for each member based on the assessment of the

needs of the member and include strategies to meet those needs. The PCCP must be evaluated for

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effectiveness and revised as the needs of the member change. The PCCP is separate and

incorporated into the CCP.

• Assisted Living providers will develop a written agreement with each ABCB member residing in their

ALF. This agreement will detail all aspects of care to be provided including identified risk factors.

Members shall be afforded the same protections from eviction as all tenants under landlord law of

state, county, city or other designated entity. It will also include the financial agreement regarding

the cost of room and board and the funding sources. A copy of this agreement and any later revisions

must be forwarded to the MCO Care Coordinator and must be maintained in the member’s file with

the MCO. The original is maintained in the member’s file at the assisted living residence.

• Assisted Living providers must meet all requirements set forth by the Licensing and Certification

Bureau/Department of Health. This would include the definition of a homelike environment

described below:

o Providers must meet the minimum, applicable qualifications set forth by the Licensing and

Certification Bureau of the Department of Health and HSD/MAD, including but not limited to:

labor/staffing rules and regulations; criminal background checks; employee abuse registry;

incident management reporting; OSHA training requirements, etc.

o Definition of Homelike Environment: A homelike environment must possess the following

structural features prior to the placement of the ABCB member. Meeting these

requirements is the financial responsibility of the Assisted Living provider:

• A minimum of 220 square feet of living space, including kitchen space for newly

constructed units. Rehabilitated units must provide a minimum of 160 square feet

of living space;

• A minimum of 100 square feet of floor space in each single bedroom. Closet and

locker areas shall not be counted as part of the available floor space. Members must

have access to a separate common living area, kitchen and bathroom that are all

accessible for persons with a disability;

• A minimum of 80 square feet of floor space per member in a semi-private bedroom

(sharing a bedroom is the member’s choice only). Closet and locker areas shall not

be counted as part of the available floor space. Members must have access to a

separate common living area, kitchen and bathroom that are all accessible for

persons with a disability;

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• Kitchens must be furnished with a sink, a refrigerator, at least a two-burner stove

top or 1.5 cubic foot microwave oven;

• Each unit must be equipped with an emergency response system;

• Common living areas must be smoke free;

• Floor plans must be submitted to the HSD/MAD along with the Medicaid Provider

Participation Application or renewal; and

• In addition, CMS requires residential settings located in the community to provide

members with the following:

o Private or semi-private bedrooms including decisions associated with sharing

a bedroom; Full access to typical facilities in a home such as a kitchen with

cooking facilities, small dining areas; All members must be given an option to

receive HCBS in more than one residential setting appropriate to their needs;

Private or semi-private bathrooms that include provisions for privacy;

Common living areas and shared common space for interaction between

members, their guests, and other residents; Members must have access to

food storage or food pantry area at all times; Members must have the

freedom and support to control their own schedules regarding their day to

day activities including having visitors of their own choosing at any time,

when and what to eat, in their home and in the community; and Members

will be treated with respect, choose to wear their own clothing, have private

space for their personal items, have privacy to visit with friends, family, be

able to use a telephone with privacy, choose how and when to spend their

free time, have easy access to resources and activities of their choosing in

the community.

▪ In provider owned or controlled residential settings, the following additional conditions will

be provided to members: Privacy in sleeping or living unit; Units have lockable entrance

doors, with members and appropriate staff having keys to doors; Members share units only

at the member’s choice and have a choice of roommates in that setting; Members have

freedom to furnish and decorate sleeping or living units as specified in the lease or

agreement; and the setting is physically accessible to the member.

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▪ Any modification of the above conditions must be supported by a specific need and justified

and documented in the PCCP to address the following:

• Identify a specific and individualized assessed need;

• Document the positive interventions and supports used prior to any modifications to

the PCCP;

• Document less intrusive methods of meeting the need that have been tried but did not

work;

• Include a clear description of the condition that is directly proportionate to the specific

assessed need;

• Include regular collection and review of data to measure the ongoing effectiveness of

the modification;

• Include established time limits for periodic reviews to determine if the modification is

still necessary or can be terminated;

• Include the informed consent of the member; and

• Include an assurance that interventions and supports will cause no harm to the

member.

Reimbursement

Billing for Assisted Living services is based on a daily rate which includes core services such as personal

care. Reimbursement for Assisted Living services will be based on the negotiated rate with the MCO.

Providers of service have the responsibility to review the prior authorizations issued from the MCO to

ensure the information on the prior authorization for their services is correct. If the provider identifies

an error, they must contact the MCO immediately to have the error corrected. An ALF may not bill the

MCO for services that the prior authorization does not cover.

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Limits or Exclusions

Assisted Living services includes core services, such as, but not limited to: personal care, transportation

and meal preparation. These services cannot be billed separately. ALF services do not include the

following ABCB services:

• Personal care services (billed separately);

• Respite;

• Environmental Modifications; and

• Emergency Response or Adult Day Health.

The Assisted Living provider is responsible for all of these services in the ALF. Therefore, billing for these

services in addition to the Assisted Living services would constitute duplication of services. Assisted

Living services require a prior authorization from a Centennial Care MCO and will not be approved

retro-actively.

• Room and Board

o The ABCB does not reimburse for room and board costs for the member (such as rent, groceries,

etc.);

o Room and board rates billed to the ABCB members must be reported to the HSD/MAD along

with the Medicaid Provider Participation Agreement (PPA) application and renewal prior to the

provision of assisted living services by the provider agency. Any subsequent changes to those

rates must also be forwarded to the HSD/MAD when they occur;

o The provider must comply with all state and Federal guidelines regarding the establishment of

room and board rates to the ABCB services recipients; and

o Training on member specific issues is reimbursable and is included in the daily rate negotiated

with the MCO.

• Non-Billable Activities

o Assisted Living providers will not bill the MCO for Room and Board;

o General training requirements are an administrative cost and are not billable; and

o The Provider will not bill when a member is hospitalized or in an institutional care setting.

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8.7. Behavior Support Consultation (BSC)

A Behavior Support Consultant is a licensed professional as specified by applicable State laws and

standards. BSC services assist the member and his or her family as well as the direct support

professionals (DSP). BSC services for the member include:

• Assessments;

• Evaluations;

• Treatments;

• Interventions; and

• Follow-up services and assistance with challenging behaviors and coping skill development.

Services for the parents, family members, and DSPs include training in dealing with challenging

behaviors and assistance with coping skill development at home and in the community.

Scope of Services/Requirements:

BSC services are initiated when the MCO Care Coordinator identifies and recommends the service be

provided to the member/member’s representative and/or family member(s). The Care Coordinator is

responsible for including recommended units of BSC services into the CCP. Strategies, support plans,

goals and outcomes will be developed based on the identified strengths, concerns and priorities in the

PCCP.

BSC services include:

o Providing assessments, evaluations, development of treatment plans and interventions, training,

monitoring of the member/member representative, and planning modification as needed for

therapeutic purposes within the professional scope of practice of the BSC;

o Designing, modifying and monitoring the use of related activities for the member/member

representative and/or family member(s) that is supportive of the PCCP;

o Training families and DSPs in relevant settings as needed for successful implementation of

therapeutic activities, strategies, and treatments;

o Consulting with the IDT member(s), guardians, family, or support staff;

o Consulting and collaborating with the member’s PCP and/or other therapists and/or medical

personnel for the purposes of evaluation of the member developing, modifying or monitoring

BSC services for the member;

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o Observing the member/member representative in all relevant settings in order to monitor the

member’s status as it relates to therapeutic goals or implementation of BSC services and

professional recommendations; and

o Services may be provided in a clinic, home, or community setting.

Comprehensive Assessment Guidelines:

o The BSC must perform an initial comprehensive assessment for each member to give the

appropriate behavior support recommendations, taking into consideration the overall array of

services received by the member. A comprehensive assessment must be done at least annually

and when clinically indicated.

Attendance at the IDT Meeting:

o The BSC is responsible for attending and participating, either in person or by conference call in

IDT meetings convened for service planning;

o If unable to attend the IDT meeting, the BSC is expected in advance of the meeting to submit

recommended updates to the strategies, support plans, and goals and objectives. The BSC and

MCO Care Coordinator will follow up after the IDT meeting to update the BSC on specific issues;

and

o The BSC must document in the member’s clinical file the date, time, and any changes to

strategies, support plans, and goals and objectives as a result of the IDT meeting.

• Discharge Planning Documentation Requirements Include:

o Reason for discontinuing services (such as failure to participate, request from member/member

representative, goal completion, and/or failure to progress);

o Written discharge plan shall be provided to the member/member representative and the MCO

Care Coordinator by the BSC;

o Strategies developed with member/member representative that can support the maintenance

of behavioral support activities;

o Family and direct support professional training that is completed in accordance with the written

discharge plan; and

o Discharge summary is to be maintained in the member’s clinical file maintained by the BSC and

a copy is to be sent to the MCO Care Coordinator and distributed to the member/member

representative.

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Other Documentation Requirements:

o Documentation must be completed in accordance with applicable HSD/MAD and Federal

guidelines;

o All documents are identified by title of document, member name, and date of documentation.

Each entry will be signed with appropriate credential(s) and name of person making entry;

o Verified Electronic Signatures may be used. BSC name and credential(s) typed on a document is

not acceptable;

o All documentation will be signed and dated by the BSC providing services;

o A copy of the annual evaluation and updated treatment plan will be provided to the MCO Care

Coordinator within 10 business days following the IDT meeting. The treatment plan must

include intervention strategies, as well as frequency and duration of care. The goals and

objectives must be measurable;

o BSC progress/summary notes will include date of service, beginning/end time of service,

location of service, description of service provided, member/family/DSP response to service,

and plan for future service;

o The summary will include the number and types of treatment provided and will describe the

progress toward BSC goals using the parameters identified in the initial and annual treatment

plan and/or evaluation;

o Any modifications that need to be included in the PCCP must be coordinated with the MCO Care

Coordinator;

o Complications that delay, interrupt, or extend the duration of the program will be documented

in the member’s medical record and in communications to the physician/health care provider as

indicated;

o Each member will have an individual clinical file maintained by the provider; and

o Review physician/health care provider orders at least annually and as appropriate and

recommend revisions to the PCCP and CCP based on evaluation findings.

Agency Provider Requirements/Qualifications:

o BSC services must be provided by an active, Medicaid approved provider type 363 BSC provider.

o Employees of a provider agency who offer BSC services shall meet all the requirements under

this section of the policy.

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o The BSC agency must be able to demonstrate that all employees providing BSC, upon

employment and thereafter, maintain (no gaps in licensure) a full permanent license through

the appropriate board of licensure. Below identifies acceptable licensure for a BSC worker:

▪ Master’s degree from an accredited school for psychology, social work, counseling or

guidance program and maintain current permanent license as required by New Mexico State

Law.

▪ Acceptable licensure includes:

• New Mexico Licensed Psychologist or Psychologist Associate.

• New Mexico Licensed Independent Social Worker (LISW).

• New Mexico Licensed Master Social Worker (LMSW).

• New Mexico Licensed Professional Clinical Counselor (LPCC).

• New Mexico Licensed Marriage and Family Therapist (LMFT).

• New Mexico Licensed Mental Health Counselor (LMHC).

o Maintain a culturally sensitive attentiveness to the needs and preferences of members and their

families based upon culture and language. Communicating in a language other than English may

be required.

Individual Provider Requirements/Qualifications:

o BSC services must be provided by an active, Medicaid approved provider type 363 BSC provider.

o An individual providing BSC services must maintain a full permanent license through DOH and

shall meet all the requirements under this section of the policy. Provisional license is not

acceptable.

o Must meet all other requirements listed under Agency Provider Qualifications/Requirements.

Reimbursement:

BSC providers are responsible for providing clinical documentation that identifies the provider’s role

in all components of the provision of care, including assessment information, care planning,

intervention, communications, and care coordination and evaluation. There must be justification in

each member’s clinical record supporting medical necessity for the care and for the approved LOC

that will also include frequency and duration of the care. All services must be reflected in the PCCP

that is coordinated with the member/member’s representative and other caregivers as applicable.

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All services provided, claimed, and billed must have documented justification supporting medical

necessity and authorized by the MCO.

Billing is on an hourly basis and is accrued to the nearest quarter hour. Training on member specific

issues are reimbursable and included in the negotiated rate. Payment for BSC services through the

MCO is considered payment in full. Reimbursement for BSC services will be based on the MCO

negotiated rate. BSC providers have the responsibility to review and ensure the information on the

prior authorization for their services is current and correct. If the provider identifies an error, they

will contact the MCO immediately to have the error corrected.

Limits or Exclusions

HSD/MAD does not consider the following to be professional BSC duties and will not authorize

payment for:

o Performing specific errands for the member/member’s representative or family that is not

program specific;

o Friendly visiting;

o Financial brokerage services, handling of member’s finances or preparation of legal documents;

o Time spent on paperwork or travel that is administrative for the provider;

o Transportation of member/member’s representative;

o Pick up and/or delivery of commodities; and

o Other non-Medicaid reimbursable activities.

8.8. Community Transition Services (CTS)

CTS are non-recurring set-up expenses for adults 21 years old and older who are transitioning from an

SNF/NF to a living arrangement in the community where the person is directly responsible for his or her

own on-going living expenses.

This service is not intended to cover the household costs of the member’s natural supports.

Allowable expenses are those necessary to enable a member to establish a basic household. CTS are

furnished only when the member is unable to meet the expenses to initially establish his/her household

or when the services cannot be obtained from other sources. CTS may not be used to furnish or

establish living arrangements owned or leased by a service provider, except an ALF. Deposits to an ALF

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are limited to $500.00. Services must be reasonable and necessary as determined by the MCO and

authorized in the transition and/or discharge plan.

Scope of Services/Requirements:

CTS must be reasonable and necessary as determined through the transition plan development process

and must be clearly identified in the discharge plan. Allowable expenses are those necessary to enable a

person to establish a basic household that do not constitute room and board and may include:

• Security deposits that are required to obtain a lease on an apartment or home. Monthly rental or

mortgage expenses are not covered; therefore, the member should have sufficient resources to pay

for the first month’s rent or mortgage as well as ongoing rent or mortgage costs;

• Essential household furnishings required to occupy and use a community domicile, including

furniture, window coverings, food preparation items, and bed/bath linens;

• Set-up fees or deposits for utility or service access, including telephone, electricity, heating and

water;

• Services necessary for the individual’s health and safety such as but not limited to, pest eradication

and one-time cleaning prior to occupancy;

• Moving expenses; and/or

• Fees to obtain a copy of birth certificate, identification card or driver’s license.

The Community Transition Agency (CTA) must be able to provide at least two of the following core

services:

o Information and referral;

o Independent living skills training;

o Peer counseling; and

o Individual and systems advocacy;

Provider Requirements/Qualifications:

The CTS may be provided directly by the MCO or contracted out to an active, Medicaid approved

provider type 363 CTA. The CTA is defined as an agency that provides CTS to individuals who are

transitioning from a SNF/NF to a home and community-based residence.

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Reimbursement

Reimbursement for CTS will be based on the negotiated rate with the MCO. Training on member

specific issues is reimbursable and included in the negotiated rate, general training requirements are an

administrative cost and are not billable.

CTS Providers have the responsibility to review the prior authorizations issued from the MCO to ensure

that the information on the prior authorization for their services is correct. If the provider identifies an

error, they must contact the MCO immediately to have the error corrected.

Limits or Exclusions

CTS do not include monthly rental or mortgage expense, food, regular utility charges, household

appliances or items that are intended for purely diversional/recreational purposes.

Additional exclusions: music systems, cable/internet, TV, VCR, DVD, MP3 player, telephone equipment,

computer, exercise equipment, personal hygiene items, decorative items, experimental or prohibited

treatments and memberships. CTS are limited to $3,500.00 per person every five years. In order to be

eligible for this service, the person must have an SNF/NF stay of at least 90 days prior to transition to the

community.

The Care Coordinator must explain this service to the member prior to discharge as part of the

community reintegration process. The member should request this service prior to discharging from the

Nursing Facility. If the member discharges from the NF to the community against medical advice (AMA)

or without MCO acknowledgement, this benefit may not be available.

Payment for a deposit to an ALF is limited to $500.00.

8.9. Emergency Response Services (ERS)

(ERS) are provided through an electronic monitoring system to secure help in the event of an

emergency. This service is to be used by ABCB members whose safety is at risk. The member may use a

portable “help” button to allow for mobility in his/her home environment. The monitoring system has a

24-hour, seven day a week monitoring capability. The system is connected to the member’s phone and

programmed to send a signal to a response center once the “help” button is activated. This response

system helps ensure that the appropriate service agency responds to alarm calls. (ERS) are provided

pursuant to the CCP.

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Scope of Services/Requirements:

Services provided by the emergency response service provider include:

o Installation, testing and maintenance of equipment;

o Training on the use of the equipment to members/caregivers and first responders;

o 24-hour monitoring for alarms;

o Monthly systems check, or more frequently if electrical outages, severe weather systems, etc.

warrant more frequent checks;

o Reports of member emergencies to the Care Coordinator and changes in the member’s

condition that may affect service delivery;

• The response center must be staffed by trained professionals; and

• Emergency Response Service categories consist of emergency response, emergency response high

need.

Provider Requirements/Qualifications:

• ERS services must be provided by an active, Medicaid approved provider type 363 ERS provider;

• In order to be approved and certified by the HSD/MAD/LTSSB, ERS providers must meet all provider

requirements/qualifications under this section. All incomplete applications submitted to the

HSD/MAD/LTSSB shall be rejected and not considered for review until a complete application is

submitted;

• The ERS provider must have emergency monitoring capability 24 hours a day, seven days a week;

• The ERS provider must be able to demonstrate it has professional trained staff to answer and

manage the response center;

• The ERS provider must be able to demonstrate it is:

o Equipped to provide verifiable data using technology capable of producing a printed record of:

▪ The type of alarm code (test, accidental or emergency);

▪ The unit subscriber number;

▪ The date; and

▪ The time of the activated alarm in seconds.

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o Emergency Response Service providers must comply with all laws, rules and regulations of the

New Mexico state corporation commission for telecommunications and security systems, if

applicable.

• Provider agencies must establish and maintain financial reporting and accounting for each member.

• Emergency Response Service providers must provide the member with information regarding

services rendered, limits of service, and information regarding agency service contracts. This

information will also include whom to contact if a problem arises, liability for payment of damages

over normal wear, and notification when change of service occurs.

• The provider agency will have security bonding.

• Emergency Response Service providers must report emergencies and changes in the member’s

condition that may affect service delivery to the MCO Care Coordinator within 24 hours.

• Emergency Response Service providers must complete quarterly reports for each member served.

The original report must be maintained in the member’s file and a copy must be submitted to the

MCO Care Coordinator on a quarterly basis.

Reimbursement

• Reimbursement for (ERS) will be based on the negotiated rate with the MCOs. Providers of service

have the responsibility to review and ensure that the information on the prior authorization for their

services is correct. If the provider identifies an error, they will contact the MCO immediately to have

the error corrected.

• A monthly fee charged can be billed to the MCO for each calendar month the member is authorized

for use of the service.

• A fee for special equipment (e.g., aa bracelet rather than a necklace) must be medically necessary

and must be substantiated and authorized by the MCO. This is designated as Emergency Response

High Need. The reason(s) for high need (ERS) must be documented in the CCP.

• All rates are based on the negotiated rate with the MCO.

Limits or Exclusions: None

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8.10. Employment Supports

Employment Supports include job development, job seeking, and job coaching supports after available

vocational rehabilitation supports have been exhausted. The job coach provides training, skill

development, and employer consultation that a member may require while learning to perform specific

work tasks on the job; co-worker training; job site analysis; situational and/or vocational assessments

and profiles; education of the eligible member and co-workers on rights and responsibilities; and

benefits counseling.

The service must be tied to a specific goal specified in the member’s CCP. Job development is a service

provided to eligible members by skilled staff.

The service has five components: 1) job identification and development activities; 2) employer

negotiations; 3) job restructuring; 4) job sampling; and 5) job placement.

Employment Supports will be provided by staff at current or potential work sites. When employment

supports are provided at a work site where persons without disabilities are employed, payment is made

only for the adaptations; supervision and training required by eligible members receiving services as a

result of their disabilities but does not include payment for the supervisory activities rendered as a

normal part of the business setting.

Scope of Services

Employment Supports facilitates competitive work in integrated work settings for individuals with

disabilities (i.e., psychiatric, mental retardation, learning disabilities, and TBI) for whom competitive

employment has not traditionally occurred, and who, because of the nature and severity of their

disability, need ongoing support services in order to perform their job. Employment Supports settings

must be integrated and support full access of members receiving Medicaid HCBS to the greater

community, including opportunities to seek employment, and work in competitive integrated settings,

engage in community life, control personal resources, and provide access to services in the community,

to the same degree of access as individuals not receiving Medicaid HCBS. Employment Supports

provides assistance such as job coaches, transportation, assistive technology, specialized job training,

and individually tailored supervision.

• Basic components of employment supports should seek to achieve the following outcomes:

o Opportunity to earn equitable wages and other employment-related benefits;

o Development of new skills;

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o Increased community participation;

o Enhanced self-esteem;

o Increased consumer empowerment; and

o Quality of life.

The types of employment supports used depend on the needs of the member. The following are the

basic components of employment supports:

o Paid Employment - Wages are a major outcome of employment supports. Work performed

must be compensated with the same benefits and wages as other workers in similar jobs

receive. This includes sick leave, vacation time, health benefits, bonuses, training opportunities,

and other benefits.

o Integrated Work Sites - Integration is one of the essential features of Employment Supports.

Members with disabilities should have the same opportunities to participate in all activities in

which other employees participate and to work alongside other employees who do not have

disabilities.

Members who are interested in pursuing work should discuss this with their MCO Care Coordinator and

ensure it is a goal within their CCP. Members should not receive Employment Supports services through

the ABCB program without first exhausting available vocational rehabilitation services. DVR services are

considered unavailable if the member is placed on the DVR waitlist.

Employment Supports does not include sheltered work or other similar types of vocational services

furnished in specialized facilities (Federal guidelines). The employment setting needs to be in an

integrated setting.

Provider Requirements/Qualifications:

• The employment supports services must be provided by an active, Medicaid approved provider type

363, Employment Supports provider;

• The employment supports provider must adhere to all rules and regulations regarding employment

supports in this section of the policy and any applicable city, county or state regulations governing

employment supports;

• The employment supports provider must be able to demonstrate it has a functioning, physical office

located in New Mexico, where staff and members can go to obtain information or assistance;

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• In order to be approved and certified by the HSD/MAD/LTSSB, Employment support providers must

meet all requirements in this section of the policy. All incomplete applications submitted to the

HSD/MAD/LTSSB shall be rejected and not considered for review until a complete application is

submitted;

• Provider Records: The provider adheres to the Department of Labor wage laws and maintains

required certificates and documentation. These documents are subject to review by the HSD/MAD.

Each member’s earnings and benefits shall be monitored by the provider in accordance with the Fair

Labor Standards Act. Each member’s earnings and benefits shall be reviewed at least semi-annually

by the Employment Supports provider to ensure the appropriateness of pay rates and benefits;

• The Provider shall maintain a confidential case file for each member and will include the following

items:

o Quarterly progress reports;

o Vocational assessment or profile; and

▪ Vocational assessments or profile is an objective analysis of a person’s interests, skills,

needs, career goals, preferences, concerns, in areas that can pertain to an employment

outcome and can ultimately be compared to the requirements and attributes of a potential

job in order to determine the degree of compatibility as well as identification of training

needs. A vocational assessment must be of a quality and content acceptable to the Division

of Vocational Rehabilitation (DVR) or HSD/MAD;

o Career development plan as incorporated in the Comprehensive Care Plan:

▪ A career development plan consists of the vocational assessment and the Work/Learn

Action Plan that specifies steps necessary towards a successful employment outcome and

identifies the people who will complete specific tasks including the individual, as well and a

review and reporting mechanism for mutual accountability.

Provider Reporting Requirements/Qualifications:

The Employment Supports provider shall submit the following to the MCO Care Coordinator;

o Quarterly Progress Reports based upon the Care Plan cycle;

o Vocational Assessment; and

o Written updates, at least every six months, to the Work/Learn Action Plan.

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Training Requirements

Providers shall retain staff trained to establish Career Development Plans. Training will be provided by

the provider necessary to ensure that employees are able to demonstrate competency in skills listed

under this policy.

• Staffing Requirements (Individual to Staff Ratio)

The provider shall ensure adequate staffing to assure health, safety, and promote positive work

behavior and growth. The amount of staff contact time shall be adequate to meet the member’s needs

and outcomes as indicated in the CCP and may vary according to purpose (e.g., job development, job

training, job stabilization, career enhancement). For Employment Supports, the staff to individual ratio is

1:1 unless otherwise specified in the CCP. For Individual Employment Supports, a minimum of 1

one-hour face-to face visit per month is required.

Staffing Requirements and Restrictions

Providers may not employ or sub-contract direct care personnel who are an immediate family member

or spouse of the member served to work in the setting in which the member is served.

• Qualification and Competencies for Employment Supports Staff: Qualifications and competencies for

staff providing job coaching/consultation services shall, at a minimum, be able to:

o Provide supports to the member as contained in the work/learn action plan and incorporated

into the CCP to achieve his or her outcomes and goals;

o Employ job-coaching techniques and to help the member learn to accomplish job tasks to the

employer’s specifications;

o Increase the member’s capacity to engage in meaningful and productive interpersonal

interactions with co-workers, supervisors and customers;

o Identify and strengthen natural supports that are available to the member at the job site and

fade paid supports in response to increased natural supports;

o Identify specific information about the member’s interests, preferences and abilities;

o Effectively communicate with the employer about how to support the member to succeed in

their employment, including any special precautions and considerations of the member’s

disability, medications, or other special concerns;

o Monitor and evaluate the effectiveness of the service and provide documentation that

demonstrates this information was effectively communicated to the MCO Care Coordinator and

the IDT members through progress notes, quarterly reports, and participation in IDT meetings;

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o Address behavioral, medical or other significant needs identified in the work/learn action

plan/CCP that require intensive one-on-one staff support;

o Communicate effectively with the member including communication through the use of

adaptive equipment if applicable, at the work site;

o Document information that pertains to the CCP, progress notes, outcomes, and health and

safety issues/concerns and any and all other required documentation by HSD/MAD;

o Adhere to relevant state policies/standards and provider policies and procedures that directly

impact services to the member;

o Model behavior, instruct and monitor any workplace requirements to the member;

o Adhere to professionally acceptable business attire and appearance, and interact and

communicate through a business-like, respectful manner; and

o Adherence to the rules of the specific workplace, including dress, confidentiality, safety rules,

and other areas required by the employer.

Supervision

• In a group employment setting (a setting where up to six individuals work in an integrated setting

with staff supports on site), the Employment Supports provider determines the job site and is

responsible for the day-to-day supervision of the members and for follow-up services. For individual

placements, the employer is responsible for the provision of general supervision consistent with his

or her role as employer. When necessary and appropriate, the Employment Support provider may

supplement these services.

Reimbursement

Employment Supports providers must maintain appropriate record keeping of services provided,

personnel and training documentation, and fiscal accountability as indicated in the Medicaid PPA. Billing

is on an hourly basis and is accrued and rounded to the nearest quarter of an hour. Reimbursements for

employment support services will be based on the negotiated rate with the MCOs. Providers of service

have the responsibility to review and ensure the information on the prior authorization for their services

is correct. If the provider identifies an error, they will contact the MCO immediately to have the error

corrected.

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Limits or Exclusions

Payment shall not be made for incentive payments, subsidies, or unrelated vocational training expenses

such as: incentive payments made to an employer to encourage or subsidize the employer's

participation in an employment supports program, payments that are passed through to users of

employment supports programs, or payments for training that is not directly related to a member’s

employment supports program. Federal financial participation cannot be claimed to defray expenses

associated with starting up or operating a business.

8.11. Environmental Modifications

Environmental modification services include the purchase and/or installation of equipment and/or

making physical adaptations to an eligible member’s residence that are necessary to ensure the health,

welfare, and safety of the member or enhance the member’s level of independence.

Scope of Services

Environmental modifications are physical adaptations and environmental control systems excluding

DME. Environmental modifications need to be identified in the member’s CCP. Adaptations include the

installation of ramps and hand rails; widening of doorways/hallways; installation of specialized electric

and plumbing systems to accommodate medical equipment and supplies; lifts/elevators; modification of

bathroom facilities (roll-in showers, sink, bathtub, and toilet modifications, water faucet controls,

lowering counters, floor urinals and bidet adaptations and plumbing); turnaround space adaptations;

specialized accessibility/safety adaptations/additions; trapeze and mobility tracks for home ceilings;

automatic door openers/doorbells; voice-activated, light-activated, motion-activated, and electronic

devices; fire safety adaptations; air filtering devices; heating/cooling adaptations; glass substitute for

windows and doors; modified switches, outlets or environmental controls for home devices; and alarm

and alert systems and/or signaling devices.

Environmental modifications are managed by professional staff available to provide technical assistance

and oversight to environmental modification projects. These modifications shall exclude those

adaptations, improvements or repairs to the existing home that do not directly affect accessibility.

Environmental modifications exclude such things as carpeting, roof repair, furnace replacement,

remodeling bare rooms, and other general household repairs.

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Provider Requirements/Qualifications:

• The environmental modifications must be provided by an active, Medicaid approved provider type

363, environmental modifications provider.

• The environmental modification provider must comply with all New Mexico State laws, rules and

regulations, including applicable building codes and the Construction Industries Licensing Act, NMSA

1978, Section 60-13-3.

• The environmental modification provider must maintain a valid New Mexico regulation and licensing

department, construction industries division GB02 class or higher construction license pursuant to

the Construction Industries Licensing Act NMSA 1978, Section 60-13-3.

• The environmental modification provider must provide a one-year warranty from the completion

date on all parts and labor. The environmental modification provider must have a working

knowledge of environmental modifications and be familiar with the needs of persons with

functional limitations in relation to environmental modifications.

• The environmental modification provider must ensure proper design criteria as addressed in

planning and design of the adaptation. The environmental modification provider is responsible for

all adaptions being made to member’s home, including but not limited to: oversight of construction

and all administrative and technical oversight of projects.

• The environmental modification provider must provide consultation to family members, waiver

providers and MCOs concerning environmental modification projects to the member’s residence

and complete a final inspection of the environmental modification project to ensure that the

adaptations meet the approved plan submitted for environmental adaptation. The MCO Care

Coordinator will also complete a final inspection to ensure the environmental modification provider

has completed the project according to authorization before final payment is made to the

environmental modification provider.

• Environmental modification providers who receive authorization from an MCO for a member project

must complete the authorized job and retain full control of the authorized project. Portions of the

authorized project may be contracted out; however, the environmental modification provider

retains full responsibility for the entire project.

• The environmental modification provider must establish and maintain financial reporting and

accounting for each member.

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o The environmental modification provider will submit the following information and

documentation to the MCO:

▪ Environmental modification evaluation;

▪ Service Cost Estimate. Photographs of the proposed modifications. The estimated start date

of the work on the proposed modification; (equipment, materials, supplies, labor, travel, per

diem, report writing time, and completion date of modification);

▪ Letter of Acceptance of service cost estimate signed by the member;

▪ Letter of Permission from property owner. If the property owner is someone other than the

member, the letter must be signed by the property owner and the member;

▪ The construction letter of understanding. If the property owner is someone other than the

member, the letter must be signed by the property owner and the member;

▪ Documentation demonstrating compliance with the ADA.

• The Provider must submit the following to the MCO Care Coordinator, after the completion of work:

o Letter of approval of work completed signed by the member; and

o Photographs of the completed modifications.

• The MCO must submit the Care Coordinator Individual Assessment of Need to the provider.

Reimbursement

Environmental modification provider agencies must maintain appropriate record keeping of services

provided, and fiscal accountability as indicated in the Medicaid PPA. Billing is based on a project basis,

one unit per environmental modification project. Reimbursement for environmental modification

services will be based on the authorized environmental modification project with the MCOs. Providers

of service have the responsibility to review and ensure the information on the prior authorization for

their services is correct. If the provider identifies an error, they will contact the MCO immediately to

have the error corrected.

The MCO Care Coordinator or other designee must visit the member’s home to ensure the

environmental authorized project reasonably appears to have been completed before final payment is

made to the environmental modification provider.

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Limits or Exclusions

Environmental modification services are limited to $5,000.00 every five years. Administrative Costs of

the provider for environmental modification services will not exceed 15% of the total cost of the

environmental modification project for each project managed by the MCO.

No duplicate adaptations, modifications or improvements shall be approved regardless of the payment

source. For example, if the client has a safe and usable ramp, a replacement ramp shall not be

approved.

This service cannot be used to fund new construction including apartment buildings and Assisted Living

facilities.

8.12. Home Health Aide (HH Aide)

HH Aide services provide total care or assist an eligible member in all ADLs. Total care is defined as: the

provision of bathing (bed, sponge, tub, or shower), shampoo (sink, tub, or bed), care of nails and skin,

oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of

motion and positioning, adequate oral nutrition and fluid intake.

Scope of Services/Requirements:

The HH Aide services assist the eligible member in a manner that promotes an improved quality of life

and a safe environment for the eligible member. HH Aide services can be provided outside the eligible

member's home. State Plan HH Aide services are intermittent and provided primarily on a short-term

basis; whereas, HH Aide services within the ABCB are provided hourly, for eligible ABCB members who

need this service on a long-term basis. HH Aides may provide basic non-invasive nursing assistant skills

within the scope of their practice. HH Aides perform procedures as an extension of nursing and therapy

services such as; bowel and bladder care, ostomy site care, personal care, walking and exercise,

household services essential to health care at home, assisting with medications that are normally

self-administered, reporting changes in patient conditions and needs, and completing appropriate

records.

HH aide services must be provided under the supervision of an RN or other appropriate professional

staff. The agency must make a supervisory visit to member's residence at least every two weeks to

observe and determine whether goals are being met.

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All supervisory visits/contacts must be documented in the member’s HH Aide clinical file on a

standardized form that reflects the following:

o Service received;

o Member’s status;

o Contact with family members; and

o Review of HH Aide PCCP with appropriate modification annually and as needed.

Provider Requirements/Qualifications:

• HH Aide services must be provided by an active, Medicaid approved provider type 363, Home Health

Agency (HHA);

• The HHA must maintain (no gaps in license) full permanent license by the New Mexico Licensing and

Certification Bureau, Division of Health Improvement; DOH as an HHA;

• In order to be approved and certified by the HSD/MAD/LTSSB, the HHA must be holding and

operating with a fully approved permanent license. All incomplete applications submitted to the

HSD/MAD/LTSSB shall be rejected and not considered for review until a complete packet is

submitted;

• The HHA nursing supervisor(s) must have at least one year of supervisory experience. The nursing

supervisor will supervise the RN, LPN and HH Aide;

• The HHA staff will be culturally sensitive to the needs and preferences of members and households.

Arrangement of written or spoken communication in another language may need to be considered;

• The HHA will document and report any noncompliance with the CCP to the MCO Care Coordinator;

• All physician orders that change the member’s service needs must be conveyed to the MCO Care

Coordinator for coordination with service providers and modification to CCP if necessary;

o The HHA will document in the member’s clinical file that the supervision of the HH Aide

occurs at least once every two weeks. Supervisory forms must be developed and

implemented specifically for this task;

o The HHA and MCO Care Coordinator must have documented monthly contact that reflects

the discussion and review of services and ongoing coordination of care;

o The HHA nursing supervisor, direct care RN and LPN shall train families, DSP and all relevant

individuals in all relevant settings as needed for successful implementation of therapeutic

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activities, strategies, treatments, use of equipment and technologies or other areas of

concern; and

o It is expected the HHA will consult with IDT members, guardians, family, and DSPs as

needed.

• Qualifications for employed HH Aides:

o HHA Certificate from an approved community-based program following the HHA training

Federal regulations 42 CFR 484.36 or the State Regulation 7 NMAC 28.2;

o HH Aide training at the licensed HHA which follows the Federal HH Aide training regulation in 42

CFR 484.36 or the State Regulation 7 NMAC 28.2;

o A CNA must have successfully completed the employing HH Agency’s written and practical

competency standards and have met the qualifications for a HH Aide. Documentation will be

maintained in personnel file;

o A HH Aide who was not trained at the employing HHA must successfully complete the employing

HHA’s written and practical competency standards before providing direct care services to an

ABCB member. Documentation will be maintained in personnel file; or

o The HH Aide will be supervised by the HH Agency nursing supervisor or designee at least once

every two weeks in the member’s home; and

o The HH Aide will be culturally sensitive to the needs and preferences of the members and their

families. Based upon the individual language needs or preferences, the HH Aide may be

requested to communicate in a language other than English.

Reimbursement

The HHA must maintain appropriate record keeping of services provided by personnel and training

documentation, and fiscal accountability as indicated in the Medicaid PPA. Billing is on an hourly basis

and is accrued and rounded to the nearest quarter of an hour. Reimbursement for HH Aide services will

be based on the negotiated rate with the MCOs. HHAs have the responsibility to review and ensure that

the information on the prior authorization for their services is correct. If the provider identifies an error,

they will contact the MCO immediately to have the error corrected.

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8.13. Nutritional Counseling

Nutritional Counseling services are designed to meet the unique food and nutritional needs of ABCB

members. These services are available to assist members living in a community setting to maintain (or

improve and maintain) their health and/or functional status and remain in their setting of choice. This

does not include oral-motor skill development services, such as those provided by a speech pathologist.

Nutritional assessment is defined as the evaluation of the nutritional needs of the ABCB member based

upon appropriate biochemical, anthropometric, physical and dietary data to determine nutrient needs

and includes recommending appropriate nutritional intake.

Nutritional counseling is defined as advising and helping an ABCB member obtain appropriate nutritional

intake by integrating information from the nutritional assessment with information on food, other

sources of nutrients, and meal preparation consistent with cultural background and socioeconomic

status.

Nutritional Counseling services may be in addition to and cannot duplicate nutritional or dietary services

allowed in the member’s Medicaid state plan benefit, or another funding source.

Scope of Services/Requirements:

Services can be initiated where they are indicated and authorized in the member’s PCCP/CCP. A PCCP

will be developed by the Nutritional Counseling provider with identified goals and measurable objectives

and will be attached to or incorporated into the CCP. The MCO should agree to the arrangements for

record-keeping, and the frequency and duration of services with the provider agency or individual

provider.

Nutritional Counseling services include:

• Assessment of nutritional needs;

• Development and/or revision of the member’s nutritional plan; and

• Counseling and nutritional intervention and observation and technical assistance related to

implementation of the nutritional plan.

The services allow for consultation with appropriate professionals, attendance at/participation in

Interdisciplinary Team meetings, liaison with the member’s representative/family/caregivers, and

monitoring of the nutritional plan.

Services are person-centered and must be culturally sensitive to the needs and preferences of the

member and their household based upon language and cultural traditions.

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The staff: client ratio is 1:1 with the member and/or the member’s representative for the period of time

in which the member is receiving Nutritional Counseling services. All services should be provided face-

to-face. They may be provided at the member’s residence or an appropriate community location.

Agency Provider Requirements/Qualifications:

• Nutritional counseling services must be provided by an active, Medicaid approved provider type 363

Nutritional Counseling provider.

• The agency must have on staff or employ a full-time licensed dietitian or a licensed nutritionist who

maintains (no gaps in licensure) a full permanent license through the New Mexico Regulation and

Licensing Department; Nutrition and Dietetics Practice Act, NMSA 1978, Section 61-7A et.seq.

Provisional permits are not acceptable.

• In order to be approved and certified by the HSD/MAD/LTSSB, Nutritional Counseling providers must

be operating with a fully approved permanent license. All incomplete applications submitted to the

HSD/MAD/LTSSB shall be rejected and not considered for review until a complete application is

submitted.

• Licensed nutrition associates will work under the supervision of a licensed dietitian or licensed

nutritionist. The provider agency must ensure that the supervision requirements for licensed

nutrition associates specified in the New Mexico Regulation and Licensing Department; Nutrition

and Dietetics Practice Act, NMSA 1978, Section 61-7A et.seq. are met.

• All licensed practitioners providing nutritional assessment and counseling services will operate

within their professional scope of practice.

• Provider agencies must comply with the HSD/MAD requirements including but not limited to: OSHA

training requirements, Incident Management reporting, Criminal Background checks, Labor Laws,

etc.

• Provider personnel must be proficient in the member’s primary language or have access to an

interpreter (family member, friend, or caregiver). Professional interpretation service fees are the

responsibility of the agency.

• Provider agencies must employ and maintain a sufficient pool of appropriately licensed and trained

personnel to provide scheduled services to all ABCB members.

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Individual Provider Requirements/Qualifications:

• Nutritional counseling services must be provided by an active, eligible, Medicaid approved

provider type 363 Nutritional Counseling provider.

• The individual must maintain a full permanent dietitian license or a nutritionist license (no gaps

in licensure) through the New Mexico Regulation and Licensing Department; Nutrition and

Dietetics Practice Act, NMSA 1978, Section 61-7A et.seq. Provisional licenses are not

acceptable.

• The individual may employ licensed nutrition associates who work under their supervision as a

licensed dietitian or licensed nutritionist. The provider must ensure that the supervision

requirements for licensed nutrition associates specified in the New Mexico Regulation and

Licensing Department; Nutrition and Dietetics Practice Act, NMSA 1978, Section 61-7A et.seq.

are met.

• All licensed practitioners providing nutritional assessment and counseling services will operate

within their professional scope of practice.

• The individual provider must comply with HSD/MAD requirements including but not limited to:

OSHA training requirements, Incident Management reporting, Criminal Background checks,

Labor Laws, etc.

• All personnel must be proficient in the member’s primary language or have access to an

interpreter (family member, friend, or caregiver). Professional interpretation service fees are

the responsibility of the agency.

• The individual provider must employ and maintain a sufficient pool of appropriately licensed

and trained personnel, sufficient to provide scheduled services to all ABCB members on their

caseload.

• Nutritional Counseling services must abide by all federal, state, HSD policies and procedures

regarding billable and non-billable items.

Reimbursement

Nutritional Counseling provider agencies and individual providers must maintain appropriate record-

keeping of services provided, personnel and training documentation, and fiscal accountability as

indicated in the Medicaid Provider Participation Agreement (PPA). All services must be reflected on a

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PCCP that is coordinated by the Care Coordinator and authorized by the MCO. Reimbursement for

Nutritional Counseling services will be based on the negotiated rate with the MCO. Billing is on an

hourly basis and is accrued and rounded to the nearest quarter of an hour. Payment for Nutritional

Counseling services through the MCO is considered payment in full. Providers of service have the

responsibility to review the prior authorizations issued from the MCO to ensure that the information on

the prior authorization for their service is correct. If the provider identifies an error, they must contact

the MCO immediately to have the error corrected.

Billable Nutritional Counseling services include:

• Attendance and/or telephone conference calls to participate in Interdisciplinary Team

meetings; and

• Training on member-specific issues is included in the negotiated rate.

Limits or Exclusions

HSD does not consider the following to be Nutritional Counseling services and will not authorize

payment for the following non-billable activities:

o General training requirements are an administrative cost and not billable;

o Performing specific errands for the individual and/or family that are not program

specific;

o Friendly visiting;

o Financial brokerage services, handling of member finances, or, preparation of legal

documents;

o Time spent on paperwork or travel that is administrative for the provider;

o Transportation of members;

o Pick up and/or delivery of commodities; and

o Other non-Medicaid reimbursable activities.

Nutritional Counseling services are provided with the understanding that the MCO is the payer of last

resort. ABCB services should not be requested or authorized until all other third party and community

resources have been explored and/or exhausted. If services are available for reimbursement through

third party liability or other payment sources, these sources must be accessed before Community

Benefit services are delivered.

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8.14. Personal Care Services (PCS)

Scope of Services

PCS have been established by HSD/MAD or Medicaid to assist individuals 21 years of age or older who

are eligible for full Medicaid coverage and meet the NF LOC criteria. This policy describes PCS for

consumers who meet NF LOC because of disability or functional limitation and need assistance with

certain ADLs and IADLs.

• The MCO determines medical LOC for PCS eligibility upon initial application and at least annually

thereafter. Medicaid-eligible individuals may contact the MCO to apply for PCS.

• The goals of PCS are to avoid institutionalization and to maintain the consumer’s functional level

and independence. Although a consumer’s assessment for the amount and types of services may

vary, PCS are not provided 24 hours a day.

• PCS is a Medicaid service, not a Medicaid category of assistance, and services are delivered pursuant

to an Individual Plan of Care (IPoC). PCS includes a range of ADL and IADL services to consumers who

meet NF LOC because of a disability or functional limitation(s). Consumers will be assessed for

services at least annually, or more frequently, as appropriate. PCS will not include those services for

a task the individual is already receiving from other sources such as tasks provided by natural

supports. Natural supports are friends, family, and the community (through individuals, clubs, and

organizations) that are able and consistently available to provide supports and services to the

consumer. The CNA is conducted pursuant to the managed care service agreement. The CNA is

performed by the MCO and determines the amount and type of services needed to supplement the

services a consumer is already receiving including those services provided by natural supports. PCS

must be related to the individual’s functional level to perform ADLs and IADLs as indicated in the

CNA.

• PCS providers will use the HSD approved EVV system to record date and time for provided PCS. PCS

agencies are responsible for establishing employment policies and providing oversight of employees

to ensure the required use of EVV as mandated in the 21st Century Cures Act.

Eligible Population

To be eligible for PCS, a member must meet all of the following criteria:

• Be a recipient of a full benefit Medicaid category of assistance and, not be receiving other Medicaid

HCBS waiver benefits, Medicaid NF, ICF/IID Medicaid, PACE, or APS attendant care program, at the

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time PCS are furnished; an individual residing in an NF or ICF/IID Medicaid is eligible to apply for PCS

to facilitate NF discharge; recipients of community transition goods or services may also receive PCS;

all individuals must meet the Medicaid eligibility requirements to receive PCS; the MCO, Medicaid or

its alternative designee must conduct an assessment (CNA) or evaluation to determine if the

transfer to PCS is appropriate and if the PCS would be able to meet the needs of that individual;

• Be age 21 or older;

• Be determined to have met NF LOC by the MCO; and

• Comply with all Medicaid and PCS regulations and procedures.

LOC Determination

To be eligible for PCS, a consumer must meet the LOC required in an NF. The MCO makes initial LOC

determination and subsequent determinations at least annually thereafter.

• The MCO approves the consumer’s LOC for a maximum of one year (12 consecutive months); a new

LOC determination must be made at least annually to ensure the consumer continues to meet

medical eligibility criteria for PCS; each LOC determination must be based on the consumer’s current

medical condition and need of service(s), and may not be based on prior year LOC determinations;

the approved NF LOC has a start date and an end date of no more than 12 consecutive months,

which is the NF LOC span.

• Any individual applying for PCS who has an existing approved NF LOC determination in another

program (i.e., NF) will not need an additional LOC determination until his/her next annual

assessment.

• A PCS agency that does not agree with the LOC determination made by the MCO or Medicaid’s

designee may work with the consumer’s physician or physician designee to request a re-review or

reconsideration from the MCO.

• A member that does not agree with the LOC determination made by the MCO may file a grievance

or appeal with the MCO. The MCO grievance or appeal process must be exhausted before the

consumer may request a fair hearing with HSD pursuant to 8.352.2 NMAC, Recipient Hearings.

• The MCO shall review the LOC determination upon a referral from the PCS agency, the consumer, or

the consumer's legal representative when a change in the consumer's health condition is identified

and make a new determination, if appropriate.

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Service Delivery Models – Consumer-Delegated PCS and Consumer-Directed PCS

• Consumers eligible for PCS have the option of choosing the consumer-delegated or the

consumer-directed personal care model. In both models, the consumer may select a family member

(except the spouse), a friend, neighbor, or other person as the attendant. The MCO’s Care

Coordinator is responsible for explaining both models to each consumer, initially, and annually

thereafter.

o In the consumer-delegated model, the consumer chooses the PCS agency to perform all

employer-related tasks and the agency is responsible for ensuring all service delivery to the

consumer.

o The consumer-directed model allows the consumer to oversee his/her own service care delivery

and requires that the consumer work with a PCS agency acting as a fiscal intermediary agency to

processing all financial paperwork to be submitted to the MCO.

Consumer’s Responsibilities

Consumers receiving PCS have certain responsibilities depending on the service delivery model they

choose.

• The consumer’s or legal representative’s responsibilities under the consumer-delegated model

include:

o Allowing the MCO to complete assessment visits and other contacts necessary to avoid a lapse

in services;

o Allowing the PCS provider to complete monthly home supervisory visits;

o Participating in the CNA process, at least annually, in the consumer’s primary place of residence;

o Participating in the development and review of the IPoC;

o Maintaining proof of current vehicle insurance (as mandated by the laws of the State of

New Mexico) if the attendant will transport the consumer in the consumer’s vehicle for support

services that have been allocated to the consumer; and

o Complying with all Medicaid rules, regulations, and PC service requirements; failure to comply

may result in discontinuation of PCS.

• The consumer’s or legal representative’s responsibilities under the consumer-directed model

include:

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o Interviewing, hiring, training, terminating, and scheduling personal care attendants; this

includes, but is not limited to:

▪ Verifying the attendant possesses a current and valid State driver’s license if there are any

driving-related activities listed on the IPoC; a copy of the current driver’s license must be

maintained in the attendant’s personnel file at all times; if no driving-related activities are

listed on the IPoC, a copy of a valid State identification is kept in the attendant’s personnel

file at all times;

▪ Verifying the attendant has proof of current liability vehicle insurance if the consumer is to

be transported in the attendant’s vehicle at any time; a copy of the current proof of

insurance must be maintained in the attendant’s personnel file at all times;

▪ Identifying training needs; this includes training his/her own attendant(s) or arranging for

training for the attendant(s);

o Developing a list of attendants who can be contacted when an unforeseen event occurs that

prevents the consumer’s regularly scheduled attendant from providing services; making

arrangements with attendants to ensure coverage and notifying the agency when arrangements

are changed;

o Verifying services have been rendered by completing, dating, signing, and submitting

documentation to the agency for payroll; a consumer or his/her legal representative is

responsible for ensuring the submission of accurate timesheets/logs; payment shall not be

issued without appropriate documentation;

o Notifying the agency, within one business day, of the date of hire or the date of termination of

his/her attendant and ensure all relevant employment paperwork and other applicable

paperwork is completed and submitted; this may include, but is not limited to: employment

application, verification from the employee abuse registry, criminal history screening, doctor’s

release to work, photo identification, proof of eligibility to work in the United States, copy of a

State driver’s license and proof of insurance;

o Notifying and submitting a report of an incident to the PCS agency within 24 hours of such

incident, so the PCS agency can submit an incident report on behalf of the consumer; the

consumer or his/her legal representative is responsible for completing the incident report;

o Ensuring the individual selected for hire has submitted a request for a nationwide caregiver

criminal history screening, pursuant to 7.1.9 NMAC and in accordance with NMSA 1978, Section

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29-17-2 et seq. of the Caregivers Criminal History Screening Act, within 20 calendar days of the

individual beginning employment; the consumer must work with the selected agency to

complete all paperwork required for submitting to the nationwide caregiver criminal history

screening; the consumer may conditionally (temporarily) employ the individual contingent upon

the receipt of written notice that the individual has submitted to a nationwide caregiver criminal

history screening; a consumer may not continue employing an attendant who does not

successfully pass a nationwide criminal history screening. The agency is responsible for the cost

of the first criminal history screening and the member and/or caregiver is responsible for any

additional caregiver history screenings and the associated costs thereafter if the caregiver’s

termination of employment is a result of termination on behalf of the member for an

unjustifiable reason not related to the agencies standard employment conditions. If the

caregiver quits or termination is a result of the caregiver failing to meet standard employment

conditions outlined by the agency, the agency will be responsible for the criminal history

screening for the next hired caregiver.

o Obtaining a signed agreement from the attendant, in which the attendant agrees that he/she

will not provide PCS while under the influence of drugs or alcohol and acknowledges that if

he/she is under the influence of drugs or alcohol while providing PCS he/she will be immediately

terminated; a copy of the signed agreement must be provided to the PCS;

o Ensuring if the attendant is the consumer’s legal representative and is the individual selected for

hire, prior approval has been obtained from Medicaid or its designee; any PCS provided by the

consumer’s legal representative must be justified, in writing, by the PCS agency and consumer

and submitted for approval to the consumer’s MCO prior to employment; the justification must

demonstrate the lack of other qualified attendants in the applicable area and indicate how

timesheets will be verified to ensure services were provided; documentation of written approval

by the consumer’s MCO must be maintained in the consumer’s file; the consumer is responsible

for immediately informing the agency if the consumer has appointed or obtained a legal

representative any time during the plan year;

o Signing an agreement accepting responsibility for all aspects of care and training including

mandatory training in cardiopulmonary resuscitation (CPR), first aid for all attendants,

competency testing, tuberculosis (TB) testing, Hepatitis B immunizations, or waiving the

provision of such training and accepting the consequences of such a waiver;

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o Verifying prior to employment, and annually thereafter, that attendants are not on the

employee abuse registry by researching the Consolidated Online Registry (COR) pursuant to

8.11.6 NMAC and in accordance with the Employee Abuse Registry Act, NMSA, Section 27-7A-1

et. seq.;

o Allowing the MCO to complete assessment visits and other contacts necessary to avoid a lapse

in services;

o Allowing the PCS provider to maintain at least a minimum of quarterly in-person contact;

o Participating in the CNA process, at least annually, in the consumer’s primary place of residence;

o Participating in the development and review of the IPoC;

o Maintaining proof of current vehicle insurance (as mandated by the laws of the State of New

Mexico) if the attendant will transport the consumer in the consumer’s vehicle for support

services that have been allocated to the consumer; and

o Complying with all Medicaid rules, regulations, and PCS requirements.

• Consumers may have a personal representative assist him/her to give instruction to the personal

care attendant or to provide information to the MCO during assessments of the consumer's natural

supports and service needs. A personal representative is not the same as a legal representative but

may be the same person. A personal representative must have the following qualifications: be at

least 18 years of age, have a personal relationship with the consumer and understand the

consumer's natural supports and service support needs, and know the consumer’s daily schedule

and routine (to include medications, medical, and functional status, likes and dislikes, strengths and

weaknesses). A personal representative does not make decisions for the consumer unless he/she is

also a legal representative, but may assist the consumer in communicating, as appropriate. A

personal representative may not be a personal care attendant, unless he/she is also the legal

representative and has obtained written approval from the MCO pursuant to these PCS regulations.

A person’s status as a personal representative must be properly documented with the PCS agency.

Agency Provider Requirements:

• Eligible PCS Agencies: PCS agencies electing to participate in providing PCS must obtain agency

certification.

• PCS agency certification: A PCS agency providing either the consumer-directed, the

consumer-delegated, or both models, must comply with the requirements of this section. PCS

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agencies must be certified by Medicaid or its designee. A PCS agency may only serve members in the

counties that are approved by HSD. An agency listing, by county, is maintained by Medicaid or its

designee. All certified PCS agencies are required to select a county in which to establish and

maintain an official office for conducting of business with published phone number and hours of

operation; the PCS agency must provide services in all areas of the county in which the main office is

located. Upon HSD approval, the PCS agency may elect to serve any county within 100 miles of the

main office. The PCS agency may elect to establish branch office(s) within 100 miles of the main

office. The PCS agency must provide PCS services to all areas of all selected counties.

• To be certified by Medicaid or its designee, agencies must meet the following conditions and submit

for approval, a packet, to Medicaid’s fiscal agent or its designee, containing the following:

o A completed Medicaid PPA (also known as the MAD 335);

o Copies of successfully passed nationwide caregivers criminal history screenings on employees

who meet the definition of “caregiver” and “care provider” pursuant to 7.1.9 NMAC and in

accordance with NMSA 1978, Section 29-17-2 et seq., of the Caregivers Criminal History

Screening Act; A copy of a current and valid business license or documentation of non-profit

status; if certified, a copy of the business license or documentation of non-profit status must be

kept current and submitted annually;

o Proof of liability and workers’ compensation insurance (if certified, proof of liability and

workers’ compensation insurance must be submitted annually to HSD and the MCO); and

o A copy of written policies and procedures that address:

▪ Medicaid’s PCS provider rules and regulations;

▪ Personnel policies; and

▪ Office details that include but are not limited to:

• Contact information, mailing address, physical location if different from mailing

address, and hours of operation for the main office and branch offices if any;

designation of counties served by the office;

• Meeting all ADA requirements; and

• If PCS agencies have branch offices, the branch office must have a qualified onsite

administrator to handle day-to-day operations and receive direction and supervision

from the main/central office;

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o Quality improvement (QI) to ensure adequate and effective operation, including documentation

of quarterly activity that addresses, but is not limited to:

▪ Service delivery;

▪ Operational activities;

▪ Critical incident and significant events management practices;

▪ QI action plan;

▪ Documentation of QI activities;

o Agency operations to furnish services as consumer-directed or consumer-delegated, or both;

o A copy of a current and valid home health license, issued by the DOH, Division of Health

Improvement, licensing, and certification (pursuant to 7.28.2 NMAC) may be submitted in lieu of

the requirements; if certified, a copy of a current and valid home health license must be

submitted annually along with proof of liability and workers’ compensation insurance; and

o Upon request, for approval to provide the consumer-delegated model of service, a copy of the

agency’s written competency test for attendants approved by Medicaid or its designee; an

agency may select to purchase a competency test or it may develop its own test; the test must

address at least the following:

▪ Communication skills;

▪ Patient/member rights, including respect for cultural diversity;

▪ Recording of information for patient/client records;

▪ Nutrition and meal preparation;

▪ Housekeeping skills;

▪ Care of the ill and disabled, including the special needs populations;

▪ Emergency response (including CPR and first aid);

▪ Universal precautions and basic infection control; home safety including oxygen and fire

safety;

▪ Incident management and reporting; and

▪ Confidentiality.

After the packet is received, reviewed, and approved in writing by Medicaid or its designee, the agency

will be contacted to complete the rest of the certification process; this will require the agency to attend

a mandatory Medicaid or its designee’s provider training session prior to the delivery of PCS.

An agency will not be certified as a personal care agency if:

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▪ It is owned in full or in part by a professional authorized to complete the CNA or other

similar assessment tool subsequently approved by Medicaid under PCS or the agency would

have any other actual or potential conflict of interest; and

▪ A conflict of interest is presumed between people who are related within the third degree

of blood or consanguinity or when there is a financial relationship between:

• Persons who are related within the third degree of consanguinity (by blood) or affinity

(by marriage) including a person’s spouse, children, parents (first degree by blood);

siblings, half-siblings, grandchildren or grandparents (second degree by blood and

uncles, aunts, nephews, nieces, great grandparents, and great grandchildren (third

degree by blood); step-mother, step-father, mother-in-law, father-in-law (first degree by

marriage); step-brother, step-sister, brothers-in-law, sisters-in-law, step grandchildren,

grandparents (second degree by marriage); step-uncles, step-aunts, step-nephews,

step-nieces, step-great grandparents, step-great grandchildren (third degree by

marriage); and

• Persons or entities with an ongoing financial relationship with each other including a

personal care provider whose principals have a financial interest in an entity or financial

relationship with a person who is authorized to complete a CNA or other similar

assessment tool or authorized to carry out any of the MCO’s responsibilities; a financial

relationship is presumed between spouses.

• Approved PCS agency responsibilities: A personal care agency electing to provide PCS under either

the consumer-directed model or the consumer-delegated model, or both, is responsible for:

o Furnishing services to Medicaid consumers that comply with all specified Medicaid participation

requirements outlined in 8.302.1 NMAC, General Provider Policies and 8.308.2.9 NMAC,

Provider Network Policies;

o Verifying every month that all consumers are eligible for full Medicaid coverage and PCS prior to

furnishing services pursuant to Subsection A of 8.302.1.11 NMAC, provider responsibilities and

requirements; PCS agencies must document the date and method of eligibility verification;

possession of a Medicaid card does not guarantee a consumer’s financial eligibility because the

card itself does not include financial eligibility, dates or other limitations on the consumer’s

financial eligibility; PCS agencies must notify consumers who are not financially eligible that

he/she cannot authorize employment for his/her attendant(s) until financial eligibility is

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resumed; PCS agencies and consumers cannot bill Medicaid or its designee for PCS services

rendered to the consumer if he/she is not eligible for PCS services;

o Using the HSD-approved EVV system;

o Maintaining appropriate recordkeeping of services provided and fiscal accountability as required

by the PPA;

o Maintaining records, as required by the PPA and as outlined in 8.302.1 NMAC, General Provider

Policies, that are sufficient to fully disclose the extent and nature of the services furnished to the

consumers;

o The PCS agency will, unless exempted by MAD or its designee, use an electronic system

attendants will use to check in and check out at the end of each period of service delivery; the

system must produce records that can be audited to determine the time of services provided,

the type of services provided, and verification by the consumer or the consumer’s legal

representative; failure by a PCS agency to maintain a proper record for audit under this system

will subject the PCS agency to recovery by Medicaid of any insufficiently documented claims;

o Passing random and targeted audits, conducted by Medicaid or its designee, that ensure

agencies are billing appropriately for services rendered; Medicaid or its designee will seek

recoupment of funds from agencies when audits show inappropriate billing or inappropriate

documentation for services;

o Providing either the consumer-directed or the consumer-delegated models, or both models;

o Furnishing to their consumers, upon request, information regarding each model; if the

consumer chooses a model an agency does not offer, the agency must refer the consumer to

the MCO for a list of agencies that offer the chosen model; the MCO is required to explain each

model in detail to each consumer annually;

o Ensuring each consumer receiving PCS services has a current IPoC on file;

o Performing the necessary nationwide caregiver criminal history screening, pursuant to 7.1.9

NMAC and in accordance with NMSA 1978, Section 29-17-2 et seq. of the Caregivers Criminal

History Screening Act, on all potential personal care attendants; nationwide caregiver criminal

history screenings must be performed by an agency certified to conduct such checks; the

agency, and the consumer, as applicable, ensures the paperwork is submitted within the first 20

calendar days of hire; consumers under the consumer-directed model or agencies under the

consumer-delegated model may conditionally (temporarily) employ an attendant until such

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check has been returned from the certified agency; if the attendant does not then successfully

pass the nationwide caregiver criminal history screening, the agency under consumer-delegated

or the consumer under consumer-directed may not continue employment of the attendant. The

agency is responsible for the cost of the first criminal history screening and the member and/or

caregiver is responsible for any additional caregiver history screenings and the associated costs

thereafter if the caregiver’s termination of employment is a result of termination on behalf of

the member for an unjustifiable reason not related to the agencies standard employment

conditions. If the caregiver quits or termination is a result of the caregiver failing to meet

standard employment conditions outlined by the agency, the agency will be responsible for the

criminal history screening for the next hired caregiver;

o Producing reports or documentation as required by Medicaid or its designee;

o Verifying consumers will not be receiving services through the following programs while they

are receiving PCS: Medicaid HCBS through the DD or MF waivers; Medicaid certified NF, ICF/IID,

PACE, or APS attendant care program; recipients of community transition goods or services may

receive Planning Center Online (PCO) services; all individuals must meet the Medicaid and LOC

eligibility requirements to receive PCS; the MCO must conduct an assessment or evaluation to

determine if the transfer is appropriate and if PCS would be able to meet the needs of that

individual; if an agency is authorized to provide services by the MCO in error, the MCO will bear

the cost of the error;

o Processing all claims for PCS in accordance with the billing specifications from the MCO;

payment shall not be issued without appropriate documentation;

o Making a referral to an appropriate social service, legal, or state agency, or the MCO for

assistance, if the agency questions whether the consumer is able to direct his/her own care or is

non-compliant with Medicaid rules and regulations; and

o Immediately reporting abuse, neglect, or exploitation pursuant to NMSA 1978, Section 27-7-30

and in accordance with the Adult Protective Services Act, by fax, within 24 hours of the incident

being reported to the agency; reportable incidents may include but are not limited to abuse,

neglect and exploitation as defined below:

▪ Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or

punishment with resulting physical harm, pain or mental anguish to a consumer;

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▪ Neglect is defined as the failure to provide goods and services necessary to avoid physical

harm, mental anguish, or mental illness to a consumer;

▪ Exploitation is defined as the deliberate misplacement or wrongful, temporary or permanent

use of a consumer’s belongings or money without the voluntary and informed consent of the

consumer; and

o Submit written incident reports to Medicaid or its designee, and the MCO, on behalf of the

consumer, within 24 hours of the incident being reported to the PCS agency; the PCS agency

must provide the consumer with an appropriate form for completion; reportable incidents may

include, but are not limited to:

▪ Death of the consumer:

• Unexpected death is defined as any death of an individual caused by an accident, or an

unknown or unanticipated cause; and/or

• Natural/expected death is defined as any death of an individual caused by a long-term

illness, a diagnosed chronic medical condition, or other natural/expected conditions

resulting in death;

▪ Other reportable incidents:

• Environmental hazard is defined as an unsafe condition that creates an immediate threat

to life or health of a consumer;

• Law enforcement intervention is defined as the arrest or detention of a person by a law

enforcement agency, involvement of law enforcement in an incident or event, or

placement of a person in a correctional facility;

• Emergency services refers to admission to a hospital or psychiatric facility or the

provision of emergency services that results in medical care that is not anticipated for

this consumer and that would not routinely be provided by a PCP; and/or

• Any reports made to APS.

o Informing the consumer and his/her attendant of the responsibilities of the agency;

o Developing an IPoC based on the assessment, services authorization, task list, and consideration

of natural supports provided by the MCO;

o Providing an informed consent form to consumers if the agency chooses not to provide

transportation services as part of support services;

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o Identifying a consumer with an improved or declining health condition or whose needs have

changed (i.e. more or less natural supports) and believe the consumer is in need of more or

fewer services should send written notification to the MCO for an LOC determination and

additional assessment of need of services; and

o Maintaining documentation in the consumer's file regarding legal and personal representatives,

as applicable.

• For agencies providing PCS under the consumer-directed model, the responsibilities include:

o Providing services through an agency with choice model or as a fiscal employer agent, and

complying with all applicable state and Federal employment laws as applicable to the provision

of such services;

▪ Agency with choice, in which the agency is the legal employer of the personal care

attendant and the consumer is the managing employer and the agency maintains at least

quarterly in-person contact with the consumer;

▪ Fiscal employer agent (FEA) in which the consumer is the legal employer of record (EOR)

and the managing employer; and the agency maintains at least quarterly in-person contact

with the consumer;

o Obtaining from the consumer or his/her legal representative a signed agreement in which the

attendant agrees that he/she will not provide PCS while under the influence of drugs or alcohol

and acknowledges that if he/she is under the influence of drugs or alcohol while providing PCS

he/she will be immediately terminated; the agency must maintain a copy of the signed

agreement in the attendant’s personnel file, for the consumer;

o Obtaining a signed agreement from each consumer accepting responsibility for all aspects of

care and training, including mandatory training in CPR, first aid for all attendants, competency

testing, TB testing, Hepatitis B immunizations, or a waiver of providing such training, and

accepting the consequences thereof; supervisory visits are not included in the

consumer-directed option; however; the agency must maintain at least quarterly in-person

contact with the consumer; a copy of the signed agreement must be maintained in the

consumer’s file;

o Encouraging the care giver to complete mental health first aid training and providing

information on where the training can be obtained;

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o Verifying, if the consumer has selected the consumer’s legal representative as the attendant,

that the consumer has obtained prior approval from Medicaid or its designee; any PCS provided

by the consumer’s legal representative must be justified, in writing, by the agency and

consumer, and submitted for approval to the MCO prior to employment; the justification must

demonstrate the unavailability of other qualified attendants in the applicable area, and indicate

how timesheets will be verified to ensure that services were provided; documentation of

written approval by the MCO must be maintained in the consumer’s file; the agency must

inform the consumer that if the consumer selects a legal representative during the plan year,

the consumer must notify the agency immediately, and the agency must ensure appropriate

documentation is maintained in the consumer’s file;

o Establishing and explaining to the consumer necessary payroll documentation for

reimbursement of PCS;

o Performing payroll activities for the attendants, such as, but not limited to, state and Federal

income tax and social security withholding and making payroll liability payments;

o Arranging for unemployment coverage and workers’ compensation insurance;

o Informing the consumer of available resources for necessary training, if requested by the

consumer, in the following areas: hiring, recruiting, training, supervision of attendants,

advertising, and interviewing techniques;

o Making a referral to an appropriate social service agency, legal agency(s) or Medicaid designee

for assistance, if the agency questions the ability of the consumer to direct his/her own care;

and

o Maintaining a consumer file, and an attendant personnel file for the consumer, for a minimum

of six years.

• For agencies providing PCS under the consumer-delegated model, the responsibilities include, but

are not limited to the following:

o Employing, terminating, and scheduling qualified attendants; and/or

o Conducting or arranging for training of all attendants for a minimum of 12 hours annually; initial

training must be completed within the first three months of employment and must include:

▪ An overview of PCS;

▪ Living with a disability or chronic illness in the community;

▪ CPR, first aid training;

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▪ A written competency test with a minimum passing score of at least 80%; expenses for all

training are to be incurred by the agency; other training may take place throughout the year

as determined by the agency; the agency must maintain in the attendant’s file: copies of all

training certifications; CPR and first aid certifications must be current;

▪ Documentation of all training must include at least: name of trainee, title of the training,

source, number of hours, and date of training;

▪ Documentation of competency testing must include at least the following: name of

individual being evaluated, date and method used to determine competency, and a copy of

the attendant’s graded competency test indicating a passing score of at least 80%; special

accommodations must be made for attendants who are not able to read or write, or who

speak, read, or write only language(s) other than English;

o Developing and maintaining a procedure to ensure trained, qualified attendants are available as

backup for regularly scheduled attendants, and for emergency situations; complete instructions

regarding the consumer’s care and a list of attendant responsibilities must be available in each

consumer’s home;

o Informing the attendant of the risks of Hepatitis B infection per current DOH or the Centers for

Disease Control and Prevention (CDC) recommendation, and offering Hepatitis B immunization

at the time of employment at no cost to the attendant; attendants are not considered to be at

risk for Hepatitis B since only non-medical services are performed; therefore attendants may

refuse the vaccine; documentation of the immunization, prior immunization, or refusal of

immunization must be in the attendant’s personnel file;

o Obtaining a copy of the attendant’s current and valid State driver’s license or other current and

valid State photo identification if the consumer is to be transported by the attendant; obtaining

a copy of the attendant’s current and valid driver’s license and current motor vehicle insurance

policy; maintaining copies of these documents in the attendant’s personnel file;

o Complying with Federal and state labor laws;

o Preparing all documentation necessary for payroll;

o Complying with Medicaid participation requirements outlined in 8.302.1 NMAC, General

Provider Policies;

o Maintaining records sufficient to fully disclose the extent, duration, and nature of services

furnished to the consumers as outlined in 8.302.1 NMAC, General Provider Policies;

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o Obtaining from the attendant a signed agreement, in which the attendant agrees that he/she

will not provide PCS while under the influence of drugs or alcohol and acknowledges that if

he/she is under the influence of drugs or alcohol while providing PCS, he/she will be

immediately terminated;

o Ensuring, if the consumer has elected the consumer’s legal representative as his/her attendant,

the agency has obtained prior approval from Medicaid or its designee; all PCS provided by the

consumer’s legal representative must be justified in writing by the agency and consumer and

submitted for approval to the MCO prior to employment; the justification must demonstrate the

unavailability of other qualified attendants in the applicable area and include a plan for

oversight by the agency to assure service delivery; documentation of approval by the MCO must

be maintained in the consumer’s file; the agency must inform the consumer that if the

consumer is appointed or selects a legal representative any time during the plan year, they must

notify the agency immediately;

o Establishing and explaining to all their consumers and all attendants the necessary

documentation needed for reimbursement of PCS;

o Performing payroll activities for the attendants;

o Providing workers’ compensation insurance for attendants; and/or

o Conducting face-to-face supervisory visits in the consumer’s residence at least monthly (12 per

service plan year); each visit must be documented in the consumer’s file indicating:

▪ Date of visit;

▪ Time of visit to include length of visit;

▪ Name and title of person conducting supervisory visit;

▪ Individuals present during visit;

▪ Review of IPoC;

▪ Identification of health and safety issues and quality of care provided by attendant, and

▪ Signature of consumer or consumer's legal representative;

o Maintaining an accessible and responsive 24-hour communication system for consumers to use

in emergency situations to contact the agency;

o Following current recommendations of DOH and CDC, as appropriate, for preventing the

transmission of TB; and

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o Verifying initially prior to employment, and annually thereafter, that attendants are not on the

employee abuse registry by researching COR pursuant to 8.11.6 NMAC and in accordance with

the Employee Abuse Registry Act, NMSA 1978, Section 27-7A-1 et seq.

• Personal Care Attendant Responsibilities: Personal care attendants providing PCS for consumers

electing either consumer-directed or consumer delegated must comply with the following

responsibilities and requirements. They include:

o Being hired by the consumer (consumer-directed model) or the PCS agency

(consumer-delegated model);

o Not being the spouse of a consumer, pursuant to 42 CFR Section 440.167;

o Providing the consumer (consumer-directed), or the PCS agency (consumer-delegated), with

proof and copies of their current valid state driver’s license or current valid state photo

identification, and if the attendant will be transporting the consumer, current valid driver’s

license and current motor vehicle insurance policy;

o Being 18 years of age or older;

o Ensuring, if the attendant is the consumer’s legal representative, and is the selected individual

for hire, prior approval has been obtained from the MCO; any PCS provided by the consumer’s

legal representative must be justified, in writing, by the PCS agency, and consumer, having been

submitted for written approval to the MCO prior to employment; the justification must

demonstrate the unavailability of other qualified attendants in the applicable area and indicate

how timesheets will be verified to ensure services were provided; documentation of approval by

the MCO must be maintained in the consumer’s file; and submit appropriate documentation of

time worked and services performed ensuring that he/she has signed his/her time

sheet/log/check list verifying the services provided to the consumer;

o Successfully passing a nationwide caregiver criminal history screening, pursuant to 7.1.9 NMAC

and in accordance with NMSA 1978, Section 29-17-2 et seq., of the Caregivers Criminal History

Screening Act, performed by an agency certified to conduct such checks; attendants are

required to submit to a criminal history screening within the first 20 calendar days of hire; an

attendant may be conditionally hired by the agency contingent upon the receipt of written

notice from the certified agency of the results of the nationwide criminal history screening;

attendants who do not successfully pass a nationwide criminal history screening are not eligible

for further PCS employment. The agency is responsible for the cost of the first criminal history

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screening and the member and/or caregiver is responsible for any additional caregiver history

screenings and the associated costs thereafter if the caregiver’s termination of employment is a

result of termination on behalf of the member for an unjustifiable reason not related to the

agencies standard employment conditions. If the caregiver quits or termination is a result of the

caregiver failing to meet standard employment conditions outlined by the agency, the agency

will be responsible for the criminal history screening for the next hired caregiver;

o Ensuring while employed as an attendant he/she will not be under the influence of drugs or

alcohol while performing PCS; the attendant must complete and sign an agreement with the

agency or consumer in which the attendant acknowledges that if he/she is under the influence

of drugs or alcohol while providing PCS he/she will be immediately terminated;

o May not be the consumer's representative, unless he/she is also the legal representative;

o If the attendant is a member of the consumer’s family, he/she may not be paid for services that

would have otherwise been provided to the consumer; if the attendant is a member of the

consumer’s household, he/she may not be paid for household services, support services

(shopping and errands), or meal preparation that are routinely provided as part of the

household division of chores, unless those services are specific to the consumer (i.e., cleaning

consumer’s room, linens, clothing, and special diets);

o An attendant may not act as the consumer’s legal representative, in matters regarding medical

treatment, financial or budgetary decision making, unless the attendant has documentation

authorizing the attendant to act in a legal capacity on behalf of the consumer;

o Following current recommendations of DOH and CDC, as appropriate for preventing the

transmission of TB;

o For consumer-delegated care only, completing 12 hours of training yearly; the attendant must

obtain certification of CPR, and first aid training within the first three months of employment,

and the attendant must maintain certification throughout the entire duration of providing PCS;

additional training will be based on the consumer’s needs as listed in the IPoC; attendants must

successfully pass a written personal care attendant competency test with at least 80% correct

within the first three months of employment; and

o Use the EVV system to document when and where PCS were provided to the member.

• Coverage Criteria: PCS have been established to assist individuals 21 years of age or older who are

eligible for full Medicaid benefits and meet the NF LOC criteria. PCS are defined as those tasks

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necessary to avoid institutionalization and maintain the consumer’s functional level and

independence. PCS are for consumers who meet NF LOC because of disability or functional

limitation and need assistance with certain ADLs and IADLs. PCS are allocated for a reasonable

accommodation of tasks to be performed by a personal care attendant, but do not provide 24 hours

per day services. A CNA is conducted pursuant to this policy, assessments for services, to determine

the amount and type of services needed to supplement the services a consumer is already receiving

including those services provided by natural supports. PCS are not provided 24 hours a day and

allocation of time and services must be directly related to an individual’s functional level to perform

ADLs and IADLs as indicated in the CNA.

o PCS are usually furnished in the consumer’s residence, except as otherwise indicated, and

during the hours specified in the consumer’s IPoC. Services may be furnished outside the

residence only when appropriate and necessary and when not available through other existing

benefits and programs, such as HH or other State plan or LTC services. If a consumer is receiving

hospice care, is a resident in an ALF, shelter home, or room and board facility, the MCO will

perform a CNA and ensure the PCS does not duplicate the services that are already being

provided. If ADL or IADL services are part of the hospice or ALF, shelter home, or room and

board facility, as indicated by the contract or admission agreement signed by the consumer, PCS

cannot duplicate those services. Regulations for assisted living facilities may be found at 7.8.2

NMAC, Assisted Living Facilities for Adults.

o PCS are not furnished to an individual who is an inpatient or resident of a hospital, NF, ICF/IID,

MH facility, correctional facility, other institutional settings, except for recipients of community

transition goods or services.

o All consumers, regardless of living arrangements, will be assessed for natural supports. PCS are

not intended to replace natural supports. Service hours will be allocated, as appropriate, to

supplement the natural supports available to a consumer. Consumers that reside with other

adult household members, that are not receiving PCS or are not disabled, will be presumed to

have household services in the common/shared areas provided by the other adult residents,

whether or not the adult residents are the selected personal care attendant. Personal care

attendants that live with the consumer will not be paid to deliver household services, support

services (shopping and errands), or meal preparation that are routinely provided as part of the

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household division of chores, unless those services are specific to the consumer (i.e., cleaning

consumer’s room, linens, clothing, and special diets). If a consumer’s living situation changes:

▪ Such that there is no longer a shared living space with another consumer, he/she will be

re-assessed for services that were allocated between multiple consumers in a shared

household; or

▪ Such that he/she begins sharing a living space with another consumer(s), all consumers in

the new shared living space will be re-assessed to determine the allocation of services

shared by all consumers residing in the household.

• Covered Services: PCS are provided as described in 8.308.12.13 NMAC. PCS will not include those

services for tasks the individual does not need or is already receiving from other sources including

tasks provided by natural supports. PCS must be related to the individual’s functional level to

perform ADLs and IADLs as indicated in the CNA conducted pursuant to this policy, assessments for

services, mobility assistance, either physical assistance or verbal prompting and cueing, may be

provided during the administration of any PCS task by the attendant. Mobility assistance includes

assistance with ambulation, transferring, or repositioning, which is defined as moving around inside

or outside the residence or consumer’s living area with or without assistive devices(s) such as

walkers, canes, and wheelchairs, or changing position to prevent skin breakdown.

o Certain PCS are provided only when the consumer has the ability to self-administer. Ability to

self-administer is defined as the ability to identify and communicate medication name, dosage,

frequency and reason for the medication. A consumer who does not meet this definition of

ability to self-administer is not eligible for these services.

o When two or more consumers living in the same residence, including assisted living facilities,

shelter homes, and other similar living arrangements, are receiving PCS, they will be assessed

both individually and jointly to determine services that are shared. Consumers sharing living

space will be assessed for services identified in Paragraphs (5) and (7) of Subsection I of

8.308.12.13 NMAC: assess each consumer individually to determine if the consumer requires

unique assistance with the service; and jointly with other household members to determine

shared living space and common needs of the household; services will be allocated based on

common needs, not based on individual needs, unless as assessed by the MCO, an individual

need for the service(s) is indicated; common needs may include meals that can be prepared for

several individuals; shopping/errands that can be completed at the same time; laundry that can

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be completed for more than one individual at the same time; dusting and vacuuming of shared

living spaces; these PCS are based on the assessment of combined needs in the household

without replacing natural and unpaid supports identified during the assessment. Description of

PCS refers to 8.308.12.13 NMAC.

• Assessments for Services: After the consumer is determined medically eligible for PCS, the MCO

determines, allocates, and authorizes PCS based on a functional assessment, which is part of the

CNA process. Although a consumer’s assessment for the amount and types of services may vary, PCS

are not provided 24 hours a day. An individual’s PCS are directly related to their functional level to

perform ADLs and IADLs as indicated by the CNA. The CNA is performed when a consumer enters

the program, at least annually or at the discretion of the MCO.

o The CNA determines the type of covered services needed by the consumer. The amount of time

allocated to each type of covered service is determined by applying and recording the

individual’s functional level to perform ADLs and IADLs. PCS are allocated for a reasonable

accommodation of tasks to be performed by a personal care attendant. A CNA determines the

amount and type of PCS needed to supplement and not duplicate the services a consumer is

already receiving including those services provided by natural supports. In the event that the

consumer’s functional needs exceed the average allocation of time allotted to perform a

particular service task per the recommendation of a medical professional, the MCO may

consider authorization of additional time based on the consumer’s verified medical and clinical

need.

o The CNA is conducted by the MCO and discussed with the consumer in the consumer’s primary

place of residence. It serves to document the current health condition and functional needs of

the consumer. It is to include no duplication of services a consumer is already receiving,

including those services provided by natural supports, and shall not be based on a prior

assessment of the consumer's health condition, functional needs, or existing services.

o Any relevant sections of the CNA and the personal care service allocation tool is sent to the PCS

agency by the MCO to allow the PCS agency to develop the IPoC.

o The CNA must be performed by the MCO upon a consumer’s initial approval for medical NF LOC

eligibility to receive PCS and at least annually thereafter, based on their assigned care

coordination level or at the MCO’s discretion. The annual CNA is completed prior to the

expiration of the current NF LOC period and determines the type and amount of services for the

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subsequent NF LOC period. The type and amount of PCS as determined by the CNA shall not be

effective prior to the start of the applicable NF LOC period. An interim assessment may be

conducted if:

▪ There is a change in the consumer’s condition (either improved or declined);

▪ There is a change in the consumer’s natural supports or living conditions; and/or

▪ The consumer requests and interim assessment.

o The MCO must explain each service delivery model at least annually to consumers enrolled in

ABCB.

o The MCO will issue a prior authorization to the PCS agency. A PCS authorization cannot extend

beyond the LOC period and must be provided to the PCS agency prior to the prior authorization

effective date and may not be applied retroactively.

o A PCS consumer who disagrees with the authorized number of hours may utilize the MCO

grievance and appeal process when enrolled in managed care. The consumer must exhaust the

appeals process with the MCO before a fair hearing can be requested pursuant to 8.352.2

NMAC, Recipient Hearings. Upon notification of the resolution of the appeal or grievance, a

member may request a fair hearing with the State. The MCO may schedule a pre-hearing

conference with the consumer to explain how the PCS regulations were applied to the

authorized service time and attempt to resolve issues prior to the fair hearing.

o Continuation of benefits: A member may continue PCS benefits while an MCO grievance and

appeal or State fair hearing decision is pending, pursuant to 8.352.2 NMAC, Recipient Hearings,

if the member requests continuation of benefits within 10 calendar days of the date of the

Notice of Action.

o The member shall be responsible for repayment of the cost of the services furnished while the

MCO grievance and appeal process or the State’s fair hearing process was pending, to the extent

the services were furnished solely because of this requirement to provide continuation of

benefits during the MCO grievance and appeal or state fair hearing process. The MCO may

recover these costs from the member, not the provider.

• IPOC: An IPoC is developed, and PCS are identified, with the appropriate assessment (CNA) for

allocating PCS. The PCS agency develops an IPoC using an MCO authorization.

The PCS agency, with the consumer’s consent, may use the authorized allocation of hours in an

individualized schedule. The individualized schedule of services allows the consumer and PCS agency

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flexibility while maintaining a focus on the consumer’s health and safety. The IPoC will clearly

document the consumer’s consent to the schedule. The PCS agency and consumer will develop the

schedule for the number of days-per-week and hours-per-day to complete the needed ADL and IADL

assistance. The PCS agency shall establish the appropriate monitoring protocols to ensure this

flexible schedule does not adversely affect the consumer’s health and safety.

Should the MCO determine, based on care coordination, IPoC reviews, or other quality oversight

that the IPoC does not adequately meet the consumer’s needs or has created a health and/or safety

concern, the MCO will communicate a request to the PCS Agency that the IPoC will need to be

adjusted to ensure the consumer’s care needs are met. The PCS agency will follow the standard IPoC

process utilizing the PCS Allocation Tool and will resubmit the IPoC for re-review within seven

calendar days from receipt of request by the MCO.

o The PCS agency must:

▪ Develop the IPoC with a specific description of the attendant’s responsibilities, including

tasks to be performed by the attendant and any special instructions related to maintaining

the health and safety of the consumer;

▪ Ensure the consumer has participated in the development of the plan and the IPoC is

reviewed and signed by the consumer or the consumer’s legal representative; a consumers’

signature on the IPoC indicates the consumer understands what services have been

identified and that services will be provided on a weekly basis for a maximum of one year; if

a consumer is unable to sign the IPoC and the consumer does not have a legal

representative, a thumbprint or personal mark (i.e., an “X”) will suffice; if signed by a legal

representative, Medicaid or its designee and the agency must have documentation in the

consumer’s file verifying the individual is the consumer’s legal representative;

▪ Maintain an approved IPoC for PCS for a maximum of one year (12 consecutive months), a

new IPoC must be developed at least annually, to ensure the consumer’s current needs are

being met; a consumer’s previous year IPoC is not used or considered in developing a new

IPoC and allocating services; a new IPoC must be developed independently at least every

year based on the consumer’s current medical condition; the tasks and number of hours in

the IPoC must match the authorized tasks and number of hours on the authorization;

▪ Submit the IPoC to the MCO for review if the IPoC varies from the PCS Allocation Tool;

Provide the consumer with a copy of their approved IPoC;

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▪ Obtain an approved task list and/or CNA;

▪ Obtain written verification the consumer, or the consumer’s legal representative,

understands if the consumer does not utilize services, for two months, the full amount of

allocated services on the IPoC, that these circumstances will be documented in the

consumer’s file; and

▪ Submit a personal care transfer/closure form (MAD 062 or other approved transfer/closure

form) to the MCO for a consumer who has passed away or who has not received services for

90 consecutive days.

• PCS are to be delivered only in the State of New Mexico. However, consumers who require PCS out

of the state may request an exception and must obtain written approval from the MCO for out of

state delivery of service prior to leaving the state. The following must be submitted for

consideration when requesting medically necessary out of state services:

o A letter from the consumer or the consumer’s legal representative requesting an out of state

exception and reasons for the request; the letter must include:

▪ The consumer’s name and SSN;

▪ How time sheets/logs/check-off list will be transmitted and payroll checks issued to the

attendant;

▪ Date the consumer will be leaving the state, including the date of the medical procedure or

other medical event, the anticipated date of return;

▪ Where the consumer will be housed after the medical procedure;

o A letter or documentation from the physician, surgeon, physician assistant, nurse practitioner,

or clinical nurse specialist verifying the date of the medical procedure; and

o A copy of the consumer’s approved IPoC and a proposed adjusted revision of services to be

provided during the time the consumer is out-of-state; support services and household services

will not be approved unless justified; if the consumer has been approved for services under

self-administered medications, a statement from the physician, physician assistant, nurse

practitioner, or clinical nurse specialist must be included indicating the consumer will continue

to have the ability to self-administer for the duration of time he/she is out-of-state.

▪ Utilization Review (UR): All PCS require prior LOC approval by the MCO; therefore,

retroactive services are not authorized. All PCS are subject to UR for medical necessity and

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program compliance. The MCO will perform UR for medical necessity. The MCO makes final

authorization of PCS using:

▪ The HSD-approved LOC criteria; and

▪ The CNA.

• PCS Agency Transfer Process: A consumer requesting to transfer services from one PCS agency to

another Medicaid-approved PCS agency may request a transfer form (MAD 062) or other approved

transfer/closure form) from his/her MCO. Transfers may only be initiated by the consumer, his/her

legal representative, or by a PCS agency on behalf of a consumer or his/her legal representative.

Transfer requests shall not be requested by the personal care attendant. Transfer approvals are

determined by the MCO and should be initiated by the consumer through the consumer’s assigned

Care Coordinator.

The following outlines the process for PCS Agency Transfers:

o The consumer must inform his/her MCO of the desire to transfer to another PCS agency;

o The consumer must complete a MAD 062 or an approved transfer form to include: the

consumer’s signature; the date of the signature of the receiving PCS agency; and the justification

for the transfer;

o The MCO will process the transfer request within 15 business days after receipt of the transfer

request;

o If approved, the MCO works with both the agency from which the consumer is currently

receiving services (originating agency) and the agency to which the consumer would like to

transfer (receiving agency) to complete the transfer;

o Originating agencies are responsible for continued provision of services until the transfer is

complete;

o Upon approval of the request, the MCO will issue a new prior authorization to the receiving

agency and make the transfer date effective 10 business days from the date of processing the

transfer. The prior authorization will include: a new prior authorization number and new DOS

and units remaining for the remainder of the IPoC year;

o The MCO will notify the consumer as well as the receiving PCS agency and issue an ending

authorization to the originating agency; and

The following outlines the MCO review process for PCS agency transfers:

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o When the MCO receives a request for a transfer from a consumer or PCS agency on behalf of a

consumer or his/her legal representative, the consumer’s Care Coordinator will interview the

consumer to determine if the request is consumer-driven;

o The Care Coordinator will ask the consumer or his/her legal guardian for specific reasons for the

transfer, including but not limited to: Will you be taking your caregiver with you? If the

consumer is taking his/her caregiver, the Care Coordinator should ask why the consumer is

requesting a transfer;

o The Care Coordinator will contact the originating and the receiving agency to investigate the

reasons given by the consumer and/or legal representative. In addition, the Care Coordinator

will ensure the consumer has notified both agencies;

o If, during the review process, the MCO determines the originating and/or receiving agency is not

compliant with the applicable Medicaid regulations, the MCO shall conduct an audit of the

agency and, if necessary, provide additional training or impose a corrective action plan (CAP).

For example, if the receiving agency has engaged in solicitation, or if the originating agency is

not sending back-up caregivers or the caregivers are not showing up on the scheduled days or

for the hours care is planned for, these issues need to be addressed by the MCO and corrected

by the agencies;

o If, during the course of the review process, the Care Coordinator finds that the consumer has

requested three transfers within a six-month period, the Care Coordinator shall meet with the

consumer and/or legal guardian to try to determine the reason for such requests and consider

whether to approve or deny the transfer;

o The consumer and/or legal guardian will not be allowed to hire an individual to be his/her

attendant who has not passed a nationwide criminal history screening or an attendant that has

been terminated from another agency for fraudulent activities or other misconduct. The Care

Coordinator will educate the consumer about the Medicaid PCS policies;

o When reviewing a transfer request, the MCO should take into consideration whether the

consumer can speak and read English. If the consumer does not speak or read English, the MCO

shall provide a translator to ensure the consumer’s options have been explained and the

consumer fully understands his/her options, and the service model selected is available to the

consumer;

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o The Care Coordinator should ensure the location of the agency or provider is convenient to the

consumer;

o A consumer who does not agree with the MCO’s decision shall utilize the MCO grievance and

appeal process;

o Upon receiving notification of the resolution of the appeal or grievance by the MCO, a consumer

may request a fair hearing pursuant to 8.352.2 NMAC, Recipient Hearings;

o The originating agency is responsible for the continuance of PCS while the hearing is pending, if

continuation of benefits is requested timely by the consumer and approved by the MCO;

All requests for change of service model (from/to, directed/delegated) must be approved by the MCO

prior to the receiving agency providing services to the consumer; and

A transfer requested by a consumer may be denied by the MCO for the following reasons:

o The consumer is requesting more hours/services;

o The consumer’s attendant or family member is requesting the transfer;

o The consumer has requested three or more transfers within a six-month period;

o The consumer wants his/her legal guardian, spouse or attorney-in-fact to be his/her attendant;

o The consumer wants an individual to be his/her attendant who has not successfully passed a

nationwide criminal history screening;

o The consumer wants an attendant who has been terminated from another agency for

fraudulent activities or other misconduct;

o The attendant does not want to complete the mandated trainings under the

consumer-delegated model;

o The consumer does not wish to comply with the Medicaid or PCS regulations and procedures;

and

o There is reason to believe that solicitation has occurred as defined in this policy in the,

Solicitation/Advertising Section in this Manual.

• Consumer Closure: The transfer/closure form may also be used by a consumer or PCS agency to

initiate closure of PCS for a member who has gone 90 consecutive days or more without PCS. The

PCS agency will submit the transfer/closure form to the MCO and the MCO will call and verify with

the consumer that PCS are no longer needed or wanted. After verification is received the MCO will

provide an end authorization to the PCS agency.

• Consumer Discharge: A consumer may be discharged from a PCS agency.

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• PCS Agency Discharge: The PCS agency may discharge a consumer for a justifiable reason, as

explained below. Prior to initiating discharge, the PCS agency must send a notice to the MCO for

approval. Once approved by the MCO, the PCS agency may initiate the discharge process with a 30-

day written notice to the consumer. The notice must include the consumer’s right to request an

appeal with the MCO and that he/she must exhaust the grievance and appeal process with the MCO

before a fair hearing can be filed with HSD pursuant to 8.352.2 NMAC, Recipient Hearings. The

notice must include the justifiable reason for the agency’s decision to discharge.

o A justifiable reason for discharge may include:

▪ Staffing problems (i.e., excessive request for change in attendants, such as three or more

during within 30 calendar days);

▪ A consumer demonstrates a pattern of verbal or physical abuse toward attendants or

agency personnel, including the use of vulgar or explicit (i.e., sexual) language, sexual

harassment, excessive use of force, use of verbal threats or physical threats, or intimidating

behavior; the agency or attendant must have documentation demonstrating the pattern of

abuse; the agency may also discharge a consumer if the life or safety of an attendant or

agency’s staff member is believed is in immediate danger;

▪ A consumer or family member demonstrates a pattern of uncooperative behavior including

not complying with agency or Medicaid regulations; not allowing the PCS agency to enter

the home to provide services; and continued requests to provide services not approved on

the IPoC;

▪ Illegal use of narcotics or alcohol abuse;

▪ Fraudulent submission of timesheets; or

▪ Living conditions or environment that may pose a health or safety risk or cause harm to the

personal care attendant, employee of an agency, MCO, or other Medicaid designee.

o The MCO must provide the consumer with a current list of Medicaid-approved personal care

agencies that service the county in which the consumer resides. The PCS agency must assist the

consumer in the discharge process, cooperate with the MCO, and continue services throughout

the discharge. If the consumer does not select another PCS agency within the 30-day time

frame, the current PCS agency must inform the MCO’s Care Coordinator and the consumer that

a lapse in services will occur until the consumer selects an agency.

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o A consumer has a right to appeal the PCS agency’s decision to suspend services. The consumer

must exhaust the MCO grievance and appeal process prior to requesting a fair hearing with HSD

as outlined in 8.352.2 NMAC, Recipient Hearings.

o Discharge by the state: Medicaid or its designee reserves the right to discontinue the

consumer’s receipt of PCS due to the consumer’s non-compliance with Medicaid regulations

and/or PCS requirements. The discontinuation of PCS does not affect the consumer’s Medicaid

eligibility. The consumer may be discharged for a justifiable reason by means of a 30-day written

notice to the consumer. The notice will include the duration of discharge, which may be

permanent, the consumer’s right to request a fair hearing, pursuant to 8.352.2 NMAC, Recipient

Hearings, and the justifiable reason for the discharge. A justifiable reason for discharge may

include:

o Staffing problems (i.e., unjustified excessive requests for change in attendants, such as three or

more during a 30-day period), excessive requests for transfers to other agencies or excessive

agency discharges;

o A consumer who demonstrates a pattern of verbal or physical abuse toward attendants, agency

personnel, or state staff or contractors, including use of vulgar or explicit sexual language, verbal

or sexual harassment, excessive use of force, demonstrates intimidating behavior, verbal or

physical threats toward attendants, agency personnel, or state staff or contractors;

o A consumer or family member who demonstrates a pattern of uncooperative behavior

including, noncompliance with agency, Medicaid program requirements or regulations or

procedures;

o Illegal use of narcotics, or alcohol abuse;

o Fraudulent submission of timesheets;

o Unsafe or unhealthy living conditions or environment; and/or

o PCS agencies and the MCO are responsible for documenting and reporting any incidents

involving a consumer to Medicaid or its designee.

Reimbursement

A Medicaid-approved PCS agency will process billings in accordance with the MCO billing instructions.

Reimbursement for PCS will be based on the negotiated rate with the MCO.

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The agency’s billed charge must be the usual and customary charge for services. “Usual and customary

charge” refers to the amount an individual provider charges the general public in the majority of cases

for a specific service and level of service.

PCS Provider Voluntary Disenrollment

A Medicaid-approved PCS agency may choose to discontinue provision of services by disenrollment.

Once approved by Medicaid or its designee, the PCS agency may initiate the disenrollment process to

assist consumers to transfer to another Medicaid approved PCS agency. The PCS agency must continue

to provide services until consumers have completed the transfer process and the agency has received

approval from Medicaid or its designee to discontinue services. Prior to disenrollment, the PCS agency

must send a notice to Medicaid or its designee for approval. The notice must include:

• Consumer notification letter;

• List of all the Medicaid approved personal care agencies serving the county in which the consumer

resides; and

• List of all consumers currently being served by the agency and the MCO in which they are enrolled.

Solicitation/Advertising

For the purposes of this section, solicitation shall be defined as any communication regarding PCS

services from an agency’s employees, affiliated providers, agents or contractors to a Medicaid member

who is not a current client that can reasonably be interpreted as intended to influence the recipient to

become a client of that entity. Individualized personal solicitation of existing or potential consumers by

an agency for their business is strictly prohibited.

• Prohibited solicitation includes, but is not limited to, the following:

o Contacting a consumer who is receiving services through another PCS or any another Medicaid

program;

o Contacting a potential consumer to discuss the benefits of its agency, including door-to-door,

telephone, mail and email solicitation;

o Offering a consumer/attendant a finder fee, higher wage, kick back, or bribe consisting of

anything of value to the consumer to obtain transfers to its agency; see 8.351.2 NMAC,

Sanctions and Remedies;

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o Directly or indirectly engaging in door-to-door, telephone, or other cold-call marketing activities

by the entity’s employees, affiliated providers, agents or contractors;

o Making false promises;

o Misinterpretation or misrepresentation of Medicaid rules, regulations or eligibility;

o Misrepresenting itself as having affiliation with another entity; and/or

o Distributing PCS-related marketing materials.

• Penalties for engaging in solicitation prohibitions: Agencies found to be conducting such activity will

be subject to sanctions and remedies as provided in 8.351.2 NMAC and applicable provisions of the

PPA.

• An agency wishing to advertise for PCS provision must first get prior written approval from Medicaid

or its designee before conducting any such activity. Advertising and community outreach materials

means materials that are produced in any medium, on behalf of a PCS agency and can reasonably be

interpreted as advertising to potential clients. Only approved advertising materials may be used to

conduct any type of community outreach. Advertising or community outreach materials must not

misrepresent the agency as having affiliation with another entity or use proprietary titles, such as

“Medicaid PCS”. Any PCS agency conducting any such activity without prior written approval from

Medicaid or its designee will be subject to sanctions and remedies as provided in 8.351.2 NMAC and

applicable provisions of the PPA.

Sanctions and Remedies

Any agency or contractor that is not compliant with the applicable Medicaid regulations is subject to

sanctions and remedies as provided in 8.351.2 NMAC.

8.15. Private Duty Nursing (PDN) for Adults

PDN services provide members who are 21 years of age and older with intermittent or extended direct

nursing care in the member’s home. All services provided under PDN require the skills of a licensed RN

or a LPN under a written physician’s order in accordance with the New Mexico Nurse Practice Act, Code

of Federal Regulation for Skilled Nursing. PDN services are planned in collaboration with the physician,

the member, and the MCO Care Coordinator. All services provided under PDN are pursuant to a

physician’s order and in conjunction with the MCO. The private duty nurse will develop and implement a

PCCP/Treatment (CMS form 485) that is separate from the CCP developed by the MCO. Members do not

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have to be homebound in order to receive this service. PDN and Medicare/Medicaid skilled nursing may

not be provided at the same time. PDN services offered through the ABCB program will vary in scope

and duration from Medicare and Medicaid skilled nursing. PDN services will be offered to members who

are 21 years of age and older receiving the CB service as the provider of last resort in accordance with

the State Medicaid Plan, State Medicaid Manual, Part 4, Section 4310 and Section 4442.1. A copy of the

written referral will be maintained in the member’s file by the PDN provider and shared with the MCO

Care Coordinator. Children (individuals under the age of 21) receive this service through the EPSDT.

PDN services are provided with the understanding that the MCO is the payer of last resort. PDN services

should not be requested or authorized until all other third party and community resources have been

explored and/or exhausted. If services are available for reimbursement through third party liability or

other payment sources, these sources must be accessed before ABCB services are delivered.

Scope of Services/Requirements:

Specific services may include the following:

• Obtaining pertinent medical history;

• Observing and assessing the member’s condition;

• Administration of medications including: oral, parenteral, gastrostomy, jejunostomy, inhalation,

rectal and topical routes;

• Providing wound care, suture removal and dressing changes;

• Monitoring feeding tubes (i.e., gastrostomy, naso-gastric, or jejunostomy including patency),

including signs of possible infection;

• Monitoring bladder program and providing care, including ostomy and indwelling catheter insertion

and removal;

• Monitoring aspiration precautions;

• Monitoring administration of oxygen, ventilator management, and member’s response;

• Monitoring infection control methods;

• Monitoring seizure protocols;

• Collecting specimens (blood, urine, stool, or sputum) and obtaining cultures as ordered by the

member’s primary physician;

• Alerting the member’s physician to any change in health status;

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• Monitoring nutritional status of the member and reporting any changes to the physician and

nutritionist if available;

• Maintaining member intake and output flow sheets as ordered by the physician;

• Performing physical assessments including monitoring of vital signs and the member’s medical

condition as warranted;

• Providing education and training to the member’s appropriate family member(s) and primary

caregiver(s) regarding care needs and treatments etc. The goal for education and training is to

encourage self-sufficiency in delivery of care by the family or primary caregiver;

• Providing staff supervision of appropriate activities, procedures and treatment;

• Developing the PCCP/treatment in collaboration with the member, and the MCO Care Coordinator.

The plan will identify and address the member’s specific needs in accordance with the physician’s

orders. Develop and implement the PCCP/treatment (CMS form 485) on the basis of the member

assessment and evaluation;

• Analyzing and interpreting member’s needs on the basis of medical history, pertinent precautions,

limitations, and evaluative findings;

• Developing interventions to assist the member to achieve and promote health to meet the

member’s needs;

• Developing individualized service goals, identifying short-and long-term goals that are measurable

and objective; and/or

• Documenting dates and types of treatments performed, as well as member’s response to

treatment and progress toward all goals.

Requirements include the following:

• The private duty nurse must perform a comprehensive assessment/evaluation for each member

and coordinate with the MCO Care Coordinator to determine appropriate services annually at a

minimum or at each visit;

• PDN services listed in the PCCP are to be within the scope of the New Mexico Nurse Practice Act,

are provided subsequent to obtaining a physician’s order and under the supervision of a RN.

Physician’s orders will contain the following:

o The task to be performed;

o How frequently the task is to be performed;

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o The duration that the order is applicable; and

o Any individualized instructions. Additionally, a physician’s order will be obtained for the

revision of any PDN service and annually with the PCCP renewal, if PDN are to continue.

• The PDN supervisor will provide clinical supervision in the member’s home at a minimum of once

each quarter. Supervision of PDN services must be documented in the member’s clinical record;

• All services must be under the order of the member’s PCP. The order will be obtained by an RN

working for the agency that provides PDN services, and will be shared with the MCO Care

Coordinator;

• The PCCP/Treatment (Form CMS-485) will be provided to the MCO Care Coordinator. Within 48

hours of any changes ordered by the physician, the provider agency will inform the MCO Care

Coordinator of physician ordered changes and the agency’s ability or inability to provide PDN in

accordance with the Care Plan. The provider agency will provide the MCO Care Coordinator with a

copy of revised orders;

• Submitting initial and quarterly progress reports to the MCO. Copies of quarterly progress reports

sent to the MCO will be maintained in the member file and will include an assessment of the

member’s current status, health and safety issues and the progress goals as listed on the

PCCP/Treatment;

• Reports must be current and available upon request of HSD/MAD;

• Reviewing and revising the PDN PCCP/Treatment making appropriate treatment modifications as

necessary and coordinate with the MCO Care Coordinator of the changes that may need to be

identified and/or changed on the CCP;

• Document complications that delay, interrupt, or extend the duration of the services in the

member’s medical record as well as communication with the member’s physician;

• Reviewing physician’s request for treatment. If appropriate, recommend revisions to the Care Plan

to the MCO Care Coordinator by requesting a conference; and

• Providing member and/or caregiver education regarding services. Document the date and time this

occurred in the member’s clinical file.

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Provider Requirements/Qualifications:

• PDN services must be provided by an active, Medicaid approved provider type 363, PDN provider;

• PDN providers must maintain (no gap in license) a full permanent license through the New Mexico

Board of Nursing;

• PDN services may also be furnished through a licensed HH Agency, licensed RHC or certified FQHC

who meet all requirements/qualifications in this section of the policy and are approved by the

HSD/MAD/LTSSB as a provider type 363, PDN provider;

• PDN providers must comply with provision of the Nurse Practice Act and all city, state and federal

rules/regulations;

• In order to be approved and certified by the HSD/MAD LTSSB, PDN providers must be operating

with a full permanent license. All incomplete applications submitted to the HSD/MAD/LTSSB shall

be rejected and not considered for review until a complete application is submitted. Provisional

licenses will not be accepted; and

• PDN providers must comply with all applicable State and Federal rules and regulations under the

Nurse Practice Act and program standards determined by HSD/MAD including but not limited to

CBCs, OSHA training requirements, incident management system reporting, labor laws, etc.

Staffing Requirements:

o An RN or LPN is considered a qualified private duty nurse when the following criteria are met:

▪ Must have current (no gaps in license) licensure as required by the state of New Mexico;

provisional licenses are not acceptable;

▪ Nursing experience preferably with disabled and elderly individuals. This includes settings

such as HH, hospital, NF facility, or other types of clinics and institutions;

▪ Nursing services must be furnished through a licensed HH Agency, licensed RHC or certified

FQHC;

▪ RNs who supervise must have at least one year of supervisory experience. Supervision of

LPNs must be provided by an RN and shall be in accordance with the New Mexico Nursing

Practice Act. The supervision of all personnel is the responsibility of the agency’s

Administrator and Director;

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▪ Be culturally sensitive to the needs and preferences of members and their households

based upon language. Communicating in a language other than English may be required;

and

▪ Hepatitis B vaccine will be offered by the provider agency upon employment at no cost to

the employee per the Federal OSHA requirements. Record of prior Hepatitis B

immunization, acceptance or denial by the employee will be maintained in the employee’s

personnel record.

Reimbursement

PDN providers are responsible for providing clinical documentation that identifies his or her role in all

components of the provision of nursing services, including assessment information, care planning,

intervention, communications, and evaluation. There must be justification in each member’s clinical

record supporting medical necessity for the care and for the level or intensity (frequency and duration)

of the care. All services must be reflected on a CCP that is coordinated with the member/member’s

representative, other caregivers as applicable, and authorized by the MCO. All services provided,

claimed, and billed must have documented justification supporting medical necessity and must be

covered by the ABCB program. Billing is on an hourly basis and is accrued and rounded to the nearest

quarter of an hour. Reimbursement for PDN for adults will be based on the negotiated rate with the

MCO. Providers have the responsibility to review and ensure the information on the prior authorization

for their services is correct. If the provider identifies an error, they will contact the MCO immediately to

have the error corrected.

• Payment for PDN services is through the MCO and is considered payment in full.

• PDN services must abide by all Federal, state, HSD, policies and procedures regarding billable and

non-billable items.

• PDN providers must ensure all insurance records are maintained correctly.

• Billable hours are as follows:

o Face-to-face activities that are described above in the scope of service for PDN;

o Attendance and/or telephone conference call to participant in IDT meetings;

o Development of the PCCP/Treatment, not to exceed four hours annually; and

o Training on member specific issues is reimbursable and included in the negotiated rate; general

training requirements are an administrative cost and not billable.

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Limits or Exclusions

• HSD/MAD does not consider the following to be professional PDN services and will not authorize

payment for the following non-billable activities:

o Performing specific errands for the member and/or family that are not program specific;

o Friendly visiting;

o Financial brokerage services, handling of member finances, or preparation of legal documents;

o Time spent on paperwork or travel that is administrative for the provider;

o Transportation of members;

o Pick up and/or delivery of commodities; and

o Other non-Medicaid reimbursable activities.

8.16. Nursing Respite Services

Nursing respite services provide the member’s primary caregiver with a limited leave of absence to

prevent burnout and provide temporary relief to meet a family crisis, emergency or caregiver’s illness as

determined in the CCP. A primary caregiver is the individual who has been identified in the PCCP and

who assists the member on a frequent basis (i.e., daily or at a minimum weekly). It is not necessary for

the primary caregiver to reside with the member in order to receive nursing respite services. Nursing

respite services may be provided in the member’s home, in the nursing respite provider’s home, and in

the community. Nursing respite services may be provided by an RN, or an LPN. Nursing respite services

are limited to a total maximum of 300 hours per PCCP year. Nursing respite services must not be

provided by a member of the member’s household or by any relative approved as the employed, paid

caregiver.

Scope of Services/Requirements:

Specific services may include the following:

• Assistance with routine ADLs such as bathing, eating, meal preparation, dressing, and hygiene;

• Assistance with routine IADLs such as general housekeeping;

• Assistance with PCS or PDN services, based on the member’s needs;

• Assistance with the enhancement of self-help skills;

• Assistance with providing opportunities for leisure, play and other recreational activities.;

Requirements include the following:

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• Nursing Respite services are available to any member of any age;

• Nursing Respite services are determined by the MCO Care Coordinator and documented on the CCP;

• Scheduling of hours for use of nursing respite services is the responsibility of the nursing respite

provider and the Care Coordinator; and

• Nursing respite services provided by a PDN provider requires a physician’s order that includes the

scope and duration of service(s). A new physician’s order will be obtained annually with the CCP

renewal or when there is a revision in the service. The order must be obtained by the agency

providing PDN and shared with the MCO Care Coordinator. The provider agency may require

advanced notice from the member/family for provision of services and will notify members of their

advanced notice requirement. The provider of nursing respite services must maintain a cumulative

record of utilization of respite care, to include time used.

Provider Requirements/Qualifications:

The provider agency of nursing respite services must meet all requirements, certifications, and training

standards set forth by the HSD/MAD to provide PDN services, as described in this section of the policy.

• Nursing respite services must be provided by an active, Medicaid approved provider type 363

Nursing Respite provider.

• Nursing respite providers must maintain (no gap in license) a full permanent license through

the New Mexico Board of Nursing. Provisional licenses will not be accepted.

o Nursing respite services may also be furnished through a licensed HH Agency, licensed

RHC or certified FQHC who meet all requirements/qualifications in this section of the

policy and are approved by the HSD/MAD/LTSSB as a provider type 363 nursing respite

provider.

• Nursing respite providers must comply with provisions of the Nurse Practice Act and the state

rules/regulations.

• In order to be approved and certified by the HSD/MAD/LTSSB, Nursing respite providers must

be holding and operating with a full permanent license (no gaps in license). All incomplete

applications submitted to the HSD/MAD/LTSSB shall be rejected and not considered for review

until a complete application is submitted.

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• Nursing respite providers must comply with all applicable State and Federal rules and

regulations under the nurse practice Act and program standards determined by HSD/MAD

including but not limited to CBCs, OSHA training requirements, incident management system

reporting, labor laws, etc.;

• Nursing respite providers must have a functioning office located in New Mexico where staff and

members can go to obtain information and/or assistance.

• The provider agency of nursing respite services must meet all requirements, certifications, and

training standards set forth by the HSD/MAD to provide PDN services, as described in this

section of the policy.

Staffing Requirements:

o An RN or LPN is considered a qualified respite nurse when the following criteria are met:

▪ Must be holding and maintaining a current (no gaps in licensure) permanent license as

required by the state of New Mexico;

▪ Nursing experience preferably with disabled and elderly individuals. This includes settings

such as HH, hospital, NF facility, or other types of clinics and institutions;

▪ RNs who supervise must have at least one year of supervisory experience. Supervision of

RNs and LPNs must be provided by a qualified RN on a quarterly basis and shall be in

accordance with the New Mexico Nursing Practice Act. The supervision of all personnel is

the responsibility of the agency’s Administrator and Director;

▪ Be culturally sensitive to the needs and preferences of members and their households

based upon language. Communicating in a language other than English may be required;

and

Hepatitis B vaccine will be offered by the provider agency upon employment at no cost to the employee

per the Federal OSHA requirements. Record of prior Hepatitis B immunization, acceptance or denial by

the employee will be maintained in the employee’s personnel record.

Supervision of nursing respite employees must be documented by the nursing respite supervisor. The

supervisor must be a staff member of the nursing respite provider agency and provide in-service training

to the personnel providing the care.

Nursing respite providers must maintain a current roster that is updated quarterly of nurse respite

providers to provide services as requested by the member or family.

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Nursing respite service providers must immediately notify the MCO Care Coordinator if there is a change

in the member’s condition, if the member refuses care or if the agency is unable to comply with the care

delivery as agreed upon in the CCP.

Reimbursement

Reimbursement is on an hourly basis and is accrued to the nearest quarter of an hour. Training on

member specific issues is reimbursable and included in the negotiated rate, general training

requirements are an administrative cost and not billable.

Reimbursement for nursing respite services will be based on the negotiated rate with the MCO.

Providers of service have the responsibility to review and ensure the information on the prior

authorization for their services is correct. If the provider identifies an error, they must contact the MCO

immediately to have the error corrected.

Limits or Exclusions

The member cannot schedule his or her own nursing respite with the nursing respite staff. The member

may receive a maximum of 300 total hours of nursing respite hours annually per CCP year provided

there is a primary caregiver. Additional hours may be requested if an eligible member’s health and

safety needs exceed the specified amount.

8.17. Respite Services

Respite services provide the member’s primary caregiver with a limited leave of absence to prevent

burnout, to reduce stress and provide temporary relief to meet a family crisis, emergency or caregiver’s

illness as determined in the CCP. A primary caregiver is the individual who has been identified in the CCP

and who assists the member on an intermittent basis (i.e., daily or as needed). Respite services provide a

temporary relief to the primary caregiver during times when he/she would normally provide unpaid

care. If a caregiver needs a break during the time when he/she provides paid care, the agency must

provide a substitute caregiver. Respite services may be provided in the member’s home, in the respite

provider’s home and/or in the community. Respite services are limited to a total maximum of 300 hours

per CCP year. Respite services does not cover or provide skilled care. If a member requires skilled care,

that care must be provided by a PDN or a nursing respite provider approved as a provider type 363,

nursing respite provider. Respite services must not be provided by a member of the member’s

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household or by any relative approved as the paid caregiver. Respite services are provided pursuant to

the CCP, developed and authorized by the member and the MCO Care Coordinator. Additional hours

may be requested if an eligible member’s health and safety needs exceed the specified amount.

Scope of Services/Requirements:

Specific respite services may include the following:

• Household Activities – The following household activities are considered necessary to maintain a

clean and safe environment and to support the member living in their home. These activities are

limited to maintenance of the member’s individual living area (i.e., kitchen, living room, bedroom,

and bathroom). For example, the respite staff would not clean the entire home if the member only

occupies three rooms in a house of six rooms. In this case, the respite caregiver would clean the

three rooms only. The respite services will assist the member in performing these activities

independently or semi-independently when appropriate. These duties are performed as indicated in

the CCP:

o Sweeping, mopping or vacuuming of carpets, hardwood floors, or linoleum;

o Dusting of furniture;

o Changing of linens;

o Doing laundry (member’s clothing and linens only);

o Cleaning bathrooms (tub and/or shower area, sink, and toilet); and/or

o Cleaning of kitchen and dining area after preparation and serving meals by the respite staff for

member, such as washing dishes, putting dishes away; cleaning counter tops, dining table where

the member ate, and sweeping the floor, etc.

• Meal Preparation – A tentative schedule for preparation of meals will be identified in the CCP as

determined by the assessment. The respite staff will assist the member in independent or

semi-independent meal preparation, including dietary restrictions per physician order.

• Personal Care – The CCP may include the following tasks to be performed by the respite provider:

o Bathing – Giving a sponge bath/bed bath/tub bath/shower, including transfer in/out;

o Dressing – Putting on, fastening, removing clothing; including prosthesis;

o Grooming – Shampooing, combing or brushing hair, applying makeup, trimming beard or

mustache, braiding hair, shaving under arms or legs as requested by the member;

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o Oral care – Brushing teeth, cleaning dentures/partials (includes use of floss, swabs, or

mouthwash). Members whose swallowing reflex is not intact, are an exception and may require

specialized oral care beyond the scope of this service as identified by a physician’s order;

o Nail care – Cleaning or filing to trim and or do cuticle care. Members with diabetes are an

exception and may require specialized nail care beyond the scope of this service as identified by

a physician’s order;

o Perineal Care – Cleansing of the perineal area and changing of sanitary napkins;

o Toileting – Transferring on/off toilet, bedside commode and/or bedpan; cleaning perinea area,

changing adult briefs/pads, readjusting clothing;

o Bowel Care – Evacuation and ostomy care, including irrigations, changing and cleaning of bags,

and ostomy site skin care. Members requiring the assistance of bowel care must be determined

medically stable by his or her physician, and are able to communicate their bowel care verbally

or in writing. A physician must prescribe a bowel program for the member. An RN is required to

provide whatever additional training the respite staff needs to ensure the respite staff is

competent to implement the member’s bowel program. The respite staff must demonstrate

competency to the nurse that he or she is able to properly implement the bowel program

according to the physician’s order(s);

o Bladder Care – Elimination, catheter care, including the changing and cleaning of catheter bag.

Members requiring the assistance of a bladder care must be determined medically stable by his

or her physician, and are able to communicate their bladder care verbally or in writing. A

physician must prescribe a bladder program for the member. An RN is required to provide

whatever additional training the homemaker staff needs to ensure the respite staff is

competent to implement the member’s bladder program. The respite staff must demonstrate

competency to the nurse that he or she is able to properly implement the bladder program

according to the physician’s order(s);

o Mobility Assistance – Assistance in ambulation, transfer and toileting, defined as follows:

▪ Ambulation – Moving around inside and/or outside the home or member’s living

area with or without assistive device(s) such as walkers, canes and wheelchairs;

▪ Transferring – Moving to/from one location/position to another with or without

assistive device(s); and/or

▪ Toileting – Transferring on or off toilet.

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o Skin Care – Observation of skin condition for maintaining good skin integrity and prevention of

skin infection, irritation, ulceration or pressure sores;

o Assisting with Self-Administered Medication – Prompting and reminding only in accordance with

the New Mexico Nursing Practice Act. Getting a glass of water or juice as requested if member is

not able to do that for himself/herself, handing the member a daily medication box or

medication bottle. For the Nurse Practice Act, refer to the PDN services in this policy;

o Eating – Assistance with eating as determined in the Care Plan. Individuals requiring tube

feeding or J-tube feedings or who are at risk for aspiration are an exception and require

specialized care as prescribed by physician;

o Range of motion exercises as described in a Therapeutic Plan developed by therapists and

taught to the caregiver and caregiver supervisor by a physical therapist or occupational

therapist;

o Support Services – Support services provide additional assistance to members in order to

promote independence and enhance his or her ability to remain in a clean and safe

environment. The following support services will be identified in the assessment of the IADLs

and are provided as determined in the Care Plan;

o Shopping and/or completing errands for the member, with or without the member;

o Accompanying or assisting with non-medical transportation.;

o Respite services are available to any member of any age; and

o Respite services are determined by the MCO Care Coordinator and documented on the CCP.

Provider Requirements/Qualifications:

• Respite services must be provided by an active, Medicaid approved provider type 363 Respite

provider.

• In order to be approved and certified by the HSD/MAD/LTSSB, respite providers must be able to

demonstrate all requirements in this section are met. All incomplete applications submitted to the

HSD/MAD/LTSSB shall be rejected and not considered for review until a complete application is

submitted;

• The respite staff must possess a current New Mexico driver’s license and a motor vehicle insurance

policy if the member is to be transported by the respite staff. Release of liability forms must be

completed and on file in the member and/or employee’s file. Respite provider agencies are not

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required to provide transportation services. The MCO Care Coordinator assesses the member’s

formal and informal support system and determine if other individuals and/or other Medicaid

agencies can provide assistance with shopping and transportation services.

o Respite agencies may be licensed by the DOH as an HH agency pursuant to 7.28.2.1 NMAC et

seq. and must meet all requirements in this section of the policy to be approved as a Medicaid

provider type 363 respite provider;

o Respite agencies must comply with DOH abuse registry screening laws regulations in accordance

with the DOH Act, NMSA 1978, section 90706(E) and the Employee Abuse Registry Act, NMSA

1978, Sections 24-27-1 to 24-27-8;

o Respite agencies must provide incident management and review on an annual basis. Maintain

documentation in the employee’s personnel file as required by HSD/MAD;

▪ Respite agencies must ensure written notification to the MCO Care Coordinator and provide

the MCO with a copy of the incident report.

o Respite agencies must comply with all requirements set forth in the Medicaid PPA;

o Respite agencies must have available and maintain a roster of trained and qualified respite

employee(s) for back-up or regular scheduling and emergencies. For members whose health and

welfare will be at risk due to absence, there should be a backup plan that ensures the member’s

health and safety;

o Respite agencies must have available in the member’s home a current copy of the CCP and any

additional materials/instructions related to the member’s care; and

o Training of the bowel and bladder care must be taught by an RN with a current license to

practice in the State of New Mexico. Upon completion the respite staff must demonstrate

competencies to perform individualized bowel and bladder programs. No respite staff will

provide bowel and bladder services prior to completion of the initial training;

o Respite supervisors must provide specific instructions to assigned respite staff on each member

prior to providing services to the member. It is the responsibility of the respite agency to ensure

that respite caregivers are appropriately trained.

Reimbursement

Respite provider agencies must maintain appropriate record keeping of services provided to personnel

and training documentation, and fiscal accountability as indicated in the Medicaid PPA. Billing is on an

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hourly basis and is accrued and rounded to the nearest quarter of an hour. Reimbursement for respite

services will be based on the negotiated rate with the MCO. Providers of respite services have the

responsibility to review and ensure the information on the prior authorization for their services is

correct. If the provider identifies an error, they will contact the MCO immediately to have the error

corrected.

ABCB respite provider agencies will use the state mandated EVV system as required by the 21st Century

Cures Act.

Limits or Exclusions

Respite services may not be provided to the member by his or her spouse. Respite services cannot be

included in the CCP in combination with Assisted Living. Respite services are limited to a total maximum

of 300 hours per CCP year. Additional hours may be requested if an eligible member’s health and safety

needs exceed the specified amount. Respite providers do not provide skilled services.

Scheduling of hours for use of respite services will be the responsibility of the member or their

representative. The provider agency may require advanced notice from the member/family for provision

of services and will notify members of their advanced notice requirement. The provider of respite

services must maintain a cumulative record of utilization of respite care, to include time used.

The member may receive a maximum of 300 hours annually unless additional hours are approved by the

MCO.

Under no circumstances may a respite staff act on behalf of a member as their representative in matters

regarding medical treatment, financial, legal or budgetary decision-making, and/or manage a member’s

finances. An immediate referral must be made to the MCO in order to determine if the member should

be referred to an appropriate social service or legal services agency(s) for assistance in these areas.

8.18. Skilled Maintenance Therapies

Skilled maintenance therapies include Occupational Therapy (OT), Physical Therapy (PT) and speech and

language therapy (SLT) for individuals 21 years and older. These services are an extension of therapy

services provided for acute and temporary conditions that are provided with the expectation that the

individual will improve significantly in a reasonable and generally predictable period of time. Skilled

maintenance therapy services are provided to adults with a focus on maintenance, community

integration, socialization and exercise, or enhance support and normalization of family relationships.

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Limits or Exclusions

A signed therapy referral for treatment must be obtained from the member’s primary care physician.

The referral will include frequency, estimated duration of therapy, and treatment/procedures to be

rendered.

8.19. Occupational Therapy (OT) for Adults

OT is a skilled therapy service for individuals 21 years and older provided by a licensed occupational

therapist. OT services promote/maintain fine motor skills, coordination, sensory integration, and/or

facilitate the use of adaptive equipment or other assistive technology. A signed OT referral for

treatment must be obtained from the member’s PCP in accordance with State laws and applicable

regulations. A copy of the written referral will be maintained in the member’s file by the occupational

therapist and shared with the MCO. The OT provider must develop a PCCP with the member and share

with the MCO Care Coordinator, which will be incorporated into the CCP. Children (under the age of 21)

receive this service through EPSDT.

OT services should not be requested or authorized until all other third party and community resources

have been explored and/or exhausted. If services are available for reimbursement through third party

liability or other payment sources, these sources must be accessed before ABCB services are delivered.

Scope of Services/Requirements:

• Teaching daily living skills;

• Developing perceptional motor skills and sensory integrative functioning;

• Designing, fabricating or modifying of assistive technology or adaptive devices;

• Providing assistive technology services;

• Designing, fabricating or applying of selected orthotic or prosthetic devices or selecting adaptive

equipment;

• Using specifically designed crafts and exercise to enhance functional performance;

• Training regarding OT activities;

• Consulting or collaborating with other service providers or family members, as directed by the

member;

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• Training of all relevant staff, family, primary caregiver, etc., in the implementation of the therapy

plan and follow up; and

• The occupational therapist must perform a comprehensive assessment evaluation for each member

to determine appropriate therapy, develop a PCCP and coordinate services with the MCO Care

Coordinator. Services may include the following:

o Obtaining pertinent medical history;

o Assessing the member for specific needs in gross/fine motor skills pertinent to OT;

o Adapting the member’s environment in order to meet his/her needs;

o Evaluating, administrating and interpreting tests;

o Assessing, interpretation and summary of objective evaluation findings, identification of

functional problems, and determining treatment goals that is objective and measurable with a

statement on potential to achieve goals;

o Administering a technically complete and correct program, using skilled techniques, that

provides for flexibility to member response;

o Establishing individualized service goals and formulate a treatment plan/PCCP on the basis of

the member’s evaluation;

▪ Analyze and interpret member’s needs on the basis of medical history, pertinent

precautions, limitations, and evaluative findings. Identify short- and long-term goals that are

measurable, objective, and related to functional mobility as determined by medical history

and evaluative findings;

▪ Formulate a treatment plan/PCCP to achieve the goals identified. The treatment plan should

include frequency, estimated duration of therapy, treatment/procedures to be rendered,

member’s response to treatment, and progress toward therapy goals with dates and time of

service;

▪ Review physician’s request for treatment, and if appropriate, recommend revisions on the

basis of evaluative findings;

▪ Implement and administer appropriate treatment;

o Providing the member or caregiver education and documenting in the member’s medical

record;

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o Preparing discharge summary and include the number and types of treatment provided. The

member disposition at discharge including functional, sensory/perceptual, and physical and

status of all levels and follow-up recommendations as indicated;

• The staff: client rate is 1:1 for the period of time in which a specific member is receiving therapy

services; and/or

• Occupational Therapy services may be provided at:

o A community-based center, i.e. therapy center;

o The member’s home; and/or

o Any other location in which the member engages in day-to-day activities.

Provider Requirements/Qualifications:

o Occupational therapy services must be provided by an active, Medicaid approved provider type

363 Occupational therapy provider.

o Occupational therapists must comply with provisions of the Occupational Therapy Act and all

other city, state and federal rules and regulations.

o Occupational therapists must maintain (no gaps in licensure) a full permanent Occupational

therapist license from the New Mexico Regulation & Licensing Department. Provisional licenses

will not be accepted.

o In order to be approved and certified by the HSD/MAD/LTSSB, Occupational Therapists must

operate with a fully approved permanent license. All incomplete applications submitted to

HSD/MAD/LTSSB shall be rejected and not considered for review until a complete application is

submitted.

o OT experience preferably in in-home care and general acute care;

o Must have access to all required diagnostic and therapeutic materials to provide services;

o Must be proficient in the member’s primary language or have access to an interpreter (family

member, friend, or caregiver). Professional interpretation service fees are the responsibility of

the agency;

o Must be culturally sensitive to the needs and preferences of members and their households

based upon language. Communicating in a language other than English may be required;

o Certified Occupational Therapy Assistants (COTA) may perform OT procedures and related tasks

pursuant to a PCCP written by the supervising licensed occupational therapist. A COTA must be

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supervised by a licensed occupational therapist. All related tasks and procedures performed by a

COTA must be within a COTA scope of service following all Federal and state requirements

applicable to COTA services;

o Provider agencies must adhere to the HSD/MAD requirements including but not limited to:

OSHA training requirements, incident management reporting, CBC, labor laws, etc.;

o Provider agencies will establish and maintain financial reporting and accounting for each

member;

o All services must be under the order of the member’s PCP. The order will be obtained by the

skilled therapist, and shared with the MCO Care Coordinator;

o Therapy reports must be current and available upon request of HSD/MAD; and

o OT providers must ensure all insurance records are maintained correctly in the member’s clinical

file.

Reimbursement

Providers are responsible for providing clinical documentation that identifies their role in all

components of the provision of OT, including assessment information, care planning, intervention,

communications, care coordination, and evaluation. There must be justification in each member’s

clinical record supporting medical necessity for the care and for the level or intensity (frequency and

duration) of the care. All services must be reflected on a Care Plan that is coordinated with the

member/member’s representative, other caregivers as applicable, and authorized by the MCO. All

services provided, claimed, and billed must have documented justification supporting medical necessity.

Reimbursement is on a per hour basis and rounded to the nearest quarter hour.

• Payment for OT services is based on the negotiated rate through the MCO and is considered

payment in full. Providers of service have the responsibility to review and ensure the information on

the prior authorization for their services is correct. If the provider identifies an error, they must

contact the MCO immediately to have the error corrected.

• OT providers must abide by all Federal, State, HSD policies and procedures regarding billable and

non-billable items.

• Billable hours are as follows:

o Face-to-face activities described in the Scope of Service;

o Maximum of eight hours for an initial comprehensive individual assessment;

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o Maximum of eight hours to develop an initial comprehensive therapy plan;

▪ Attendance and/or telephone conference call to participate in IDT meetings;

▪ Annual maximum of six hours to complete progress reports and/or to revise annual plan;

▪ Annual maximum of eight hours to arrange assistive technology development;

▪ Training on member specific issues is reimbursable, general training requirements are an

administrative cost and not billable.

Limits or Exclusions

• HSD does not consider the following to be professional OT services and will not authorize payment

for the following non-billable activities:

o Performing specific errands for the member and/or family that are not program specific;

o Friendly visiting;

o Financial brokerage services, handling of member finances, or, preparation of legal documents;

o Time spent on paperwork or travel that is administrative for the provider;

o Transportation of members;

o Pick up and/or delivery of commodities; and

o Other non-Medicaid reimbursable activities.

8.20. Physical Therapy (PT) for Adults

PT is a skilled therapy service for members 21 years and older provided by licensed Physical therapist. PT

services promote/maintain gross/fine motor skills, facilitate independent functioning and/or prevent

progressive disabilities. A signed PT referral for treatment must be obtained from the member’s PCP in

accordance with State laws and applicable regulations. A copy of the written referral will be maintained

in the member’s file by the physical therapist and shared with the MCO Care Coordinator. Children

(under the age of 21) receive this service through EPSDT.

PT services should not be requested or authorized until all other third party and community resources

have been explored and/or exhausted. If services are available for reimbursement through third party

liability or other payment sources, these sources must be accessed before ABCB services are delivered.

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Scope of Services/Requirements:

• Providing professional assessment(s) of the individual for specific needs in gross/fine motor skills;

• Developing, implementing, modifying and monitoring PT treatments and interventions for the

member;

• Designing, modifying or monitoring use of related environmental modifications;

• Designing, modifying and monitoring use of related activities supportive to the Care Plan goals and

objectives;

• Consulting or collaborating with other service providers or family members, as directed by the

member or Care Coordinator;

• Using of equipment and technologies or any other aspect of the member’s PT services;

• Training regarding PT activities;

• Training of all relevant staff, family, primary caregiver, etc., in the implementation of the therapy

plan and follow up.

• The physical therapist must perform a comprehensive assessment evaluation and develop a PCCP

for each member to determine appropriate therapy and coordinate services with the MCO Care

Coordinator. Services may include the following:

o Obtaining pertinent medical history;

o Assessing of the member on physical strengths and deficits including, but limited to:

▪ Range of motion for all joints;

▪ Muscle strength, gait pattern, sensation, balance, coordination, and perception;

▪ Skin integrity and respiratory status;

o Functional level of motor developmental level;

o Adapting the member’s environment in order to meet his/her needs;

o Evaluating, including the administration and interpreting tests and measurements within the

scope of the therapist;

o Assessing interpretation and summary of objective evaluation findings, identification of

functional problems, and determining treatment goals that are objective and measurable with a

statement on potential to achieve goals;

o Administering a technically complete and correct program, using skilled techniques, that

provides for flexibility to member response;

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o Establishing individualized service goals and formulate a treatment plan on the basis of the

member evaluation;

o Analyze and interpret member’s needs on the basis of medical history, pertinent precautions,

limitations, and evaluative findings;

o Identify short- and long-term goals that are measurable, objective, and related to functional

mobility as determined by medical history and evaluative findings. Formulate a treatment

plan/PCCP to achieve the goals identified. The Treatment Plan should include frequency,

estimated duration of therapy, treatment/procedures to be rendered, member’s response to

treatment, and progress toward therapy goals with dates and time of service;

o Review physician’s request for treatment, and if appropriate, recommend revisions on the basis

of evaluative findings;

o Implement and administer appropriate treatment;

o Providing the member or caregiver education and documenting in the member’s medical

record; and

o Preparing discharge summary and include the number and types of treatment provided. The

member disposition at discharge including functional mobility level and follow-up

recommendations as indicated.

• The staff to client ratio is 1:1 for the period of time in which a specific member is receiving therapy

services; and/or

o Therapy services may be provided at:

▪ A community-based center (i.e., therapy center);

▪ The member’s home; and/or

▪ Any other location in which the member engages in day-to-day activities.

Provider Requirements/Qualifications:

o Physical therapy services must be provided by an active, Medicaid approved provider type 363

Physical therapist provider.

o Physical therapists must comply with all provisions and city, state and federal rules regarding

physical therapy.

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o Physical therapists must maintain (no gaps in licensure) a full permanent physical therapist

license from the New Mexico Regulation & Licensing Department. Provisional licenses will not

be accepted.

o In order to be approved and certified by the HSD/MAD/LTSSB, Physical Therapists must be

holding and operating with a fully approved permanent license. All incomplete applications

submitted to HSD/MAD/LTSSB shall be rejected and not considered for review until a complete

application is submitted.

• Staffing Requirements:

▪ PT experience preferably in in-home care and general acute care;

▪ Must have access to all required diagnostic and therapeutic materials to provide services;

▪ Must be proficient in the member’s primary language or have access to an interpreter

(family member, friend, or caregiver). Professional interpretation service fees are the

responsibility of the agency;

▪ Must be culturally sensitive to the needs and preferences of members and their households

based upon language. Communicating in a language other than English may be required;

and

▪ Certified Physical Therapy Assistants (PTA) may perform PT procedures and related tasks

pursuant to a PCCP written by the supervising licensed physical therapist. A PTA must be

supervised by a licensed physical therapist. All related tasks and procedures performed by a

PTA must be within a PTA scope of service following all Federal and state requirements

applicable to PTA services.

• Administrative Requirements:

o Provider agencies must adhere to HSD/MAD requirements including but not limited to: OSHA

training requirements, incident management reporting, CBC, labor laws, etc.;

o All services must be under the order of member’s PCP. The order will be obtained by the skilled

therapist, and shared with the MCO Care Coordinator; and

o Therapy reports must be current and available upon request of HSD/MAD.

Reimbursement

Reimbursement for PT services will be based on the negotiated rate with the MCO. Providers of service

have the responsibility to review and ensure that the information on the prior authorization for their

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services is correct. If the provider identifies an error, they must contact the MCO immediately to have

the error corrected.

PT services are provided with the understanding the MCO is the payer of last resort. PT services should

not be requested or authorized until all other third party and community resources have been explored

and/or exhausted. If services are available for reimbursement through third party liability or other

payment sources, these sources must be accessed before ABCB services are delivered.

Each provider of PT services is responsible to provide clinical documentation that identifies his or her

role in all components of the provision of PT, including assessment information, care planning,

intervention, communications, care coordination, and evaluation. There must be justification in each

member’s clinical record supporting medical necessity for the care and for the level or intensity

(frequency and duration) of the care. All services must be reflected on a Care Plan that is coordinated

with the member/member representative, other caregivers as applicable, and authorized by the MCO.

All services provided, claimed, and billed must have documented justification supporting medical

necessity.

• PT services must abide by all Federal, State, HSD policies and procedures regarding billable and

non-billable items; and

• PT providers must ensure all insurance records are maintained correctly.

Billable hours are as follows:

o Face-to-face activities described in the Scope of Service;

o Maximum of eight hours for an initial comprehensive individual assessment;

o Maximum of eight hours to develop an initial comprehensive therapy plan;

▪ Attendance and/or telephone conference call to participate in IDT meetings;

▪ Annual maximum of six hours to complete progress reports and/or to revise annual plan;

▪ Annual maximum of eight hours to arrange assistive technology development;

• Reimbursement is on a unit rate per hour and rounded to the nearest quarter hour;

• Training on member specific issues is reimbursable, general training requirements are

an administrative cost and not billable;

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Limits or Exclusions

• HSD does not consider the following to be professional PT services and will not authorize payment

for the following non-billable activities:

o Performing specific errands for the individual and/or family that are not program specific;

o Friendly visiting;

o Financial brokerage services, handling of member finances, or, preparation of legal documents;

o Time spent on paperwork or travel that is administrative for the provider;

o Transportation of members;

o Pick up and/or delivery of commodities; and

o Other non-Medicaid reimbursable activities.

8.21. Speech Language Therapy (SLT) for Adults

SLT is a skilled therapy service for individuals 21 years and older provided by a licensed speech and

language pathologist. SLT services preserve abilities for independent function in communication; to

facilitate oral motor and swallowing function, to facilitate use of assistive technology, and to prevent

progressive disabilities. A signed speech therapy referral for treatment must be obtained from the

member’s PCP in accordance with State laws and applicable regulations. A copy of the written referral

will be maintained in the member’s file by the speech language therapist and shared with the MCO Care

Coordinator. Children (under age 21) receive this service through EPSDT.

SLT services should not be requested or authorized until all other third party and community resources

have been explored and/or exhausted. If services are available for reimbursement through third party

liability or other payment sources, these sources must be accessed before ABCB services are delivered.

Scope of Services/Requirements:

Specific services may include the following:

• Identification of communicative or oropharyngeal disorders and delays in the development of

communication skills;

• Prevention of communicative or oropharyngeal disorders and delays in the development of

communication skills;

• Use of specifically designed equipment, tools, and exercises to enhance functional performance;

• Design, fabrication or modification of assistive technology or adaptive devices;

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• Provision of assistive technology services;

• Evaluation, including administering and interpreting tests;

• Adapting the member’s environment in order to meet his/her needs;

• Implementation of the maintenance therapy plan;

• Training of all relevant staff, family, primary caregiver, etc., in the implementation of the therapy

plan and follow up;

• Consulting or collaborating with other service providers or family members; and

• Development of eating or swallowing plans and monitoring their effectiveness.

• The speech language therapist must perform a comprehensive assessment evaluation for each

member to determine appropriate therapy and coordinate services with the MCO Care Coordinator.

Services may include the following:

o Obtaining pertinent medical history;

o Assessing for speech language disorders;

o Assessing for swallowing disorders (dysphasia);

o Assessing of communicative functions including underlying processes (i.e., cognitive skills,

memory, attention, perception, and auditory processing, includes ability to convey or receive a

message effectively and independently, regardless of the mode);

o Assessing of oral motor function;

o Assessing for the use of prosthetic/adaptive devices;

o Assessing of resonance and nasal airflow;

o Assessing of orofacial myofunctional patterns;

o Assessing interpretation and summary of objective evaluation findings, identification of

functional problems, and determining treatment goals that are objective and measurable with a

statement on potential to achieve goals;

o Administering a technically complete and correct program, using skilled techniques, that

provides for flexibility to member response;

o Establishing individualized service goals and formulate a treatment plan on the basis of the

member evaluation;

o Analyze and interpret member’s needs on the basis of medical history, pertinent precautions,

limitations, and evaluative findings;

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o Identify short- and long-term goals that are measurable, objective, and related to

augmentative/alternative communication and/or device treatment/orientation, orofacial

myofunctional treatment, prosthetic/device treatment/orientation, swallowing function

treatment, voice treatment, central auditory processing treatment, etc.;

o Formulate a treatment plan to achieve the goals identified. The treatment plan should include

frequency, estimated duration of therapy, treatment/procedures to be rendered, member’s

response to treatment, and progress toward therapy goals with dates and time of service;

o Review physician’s request for treatment, and if appropriate, recommend revisions on the basis

of evaluative findings;

o Implement and administer appropriate treatment;

o Providing the member or caregiver education and documenting in the member’s medical

record;

o Preparing discharge summary and include the number and types of treatment provided. The

member disposition at discharge including functional, sensory/perceptual, and physical and

status of all levels and follow-up recommendations as indicated;

o The staff to client rate is 1:1 for the period of time in which a specific member is receiving

therapy services; and

o Therapy services may be provided at:

▪ A community-based center (i.e., therapy center);

▪ The member’s home; and/or

▪ Any other location in which the member engages in day-to-day activities.

Provider Requirements/Qualifications:

SLT services must be provided by an active, Medicaid approved provider type 363 SLT provider.

SLT providers must maintain (no gaps in licensure) a full permanent license by the New Mexico

Regulation & Licensing Department. Provisional licenses will not be accepted.

In order to be approved and certified by the HSD/MAD/LTSSB, SLT providers must be operating with a

fully approved permanent license. All incomplete applications submitted to HSD/MAD/LTSSB shall be

rejected and not considered for review until a complete application is submitted.

• Staffing Requirements:

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o Graduation from an accredited masters or doctoral degree level, and holding the Certificate of

Clinical Competence from the American Speech Language Hearing Association;

o Must have a current licensure by State of New Mexico;

o SLT experience preferably in in-home care and general acute care;

o Must have access to all required diagnostic and therapeutic materials to provide services;

o Must be proficient in the member’s primary language or have access to an interpreter (family

member, friend, or caregiver). Professional interpretation service fees are the responsibility of

the agency; and

o Must be culturally sensitive to the needs and preferences of members and their households

based upon language. Communicating in a language other than English may be required.

• Administrative Requirements:

o Provider agencies must adhere to the HSD/MAD requirements including but not limited to:

OSHA training requirements, incident management reporting, CBC, labor laws, etc.;

o Provider agencies will establish and maintain financial reporting and accounting for each

member;

o All services must be under the order of the member’s PCP. The order will be obtained by the

skilled therapist, and shared with the MCO Care Coordinator; and

o Therapy reports must be current and available upon request of HSD/MAD.

Reimbursement

• SLT providers are responsible for providing clinical documentation that identifies his or her role in all

components of the provision of home care, including assessment information, care planning,

intervention, communications, care coordination, and evaluation. There must be justification in each

member’s clinical record supporting medical necessity for the care and for the level or intensity

(frequency and duration) of the care. All services must be reflected on a Care Plan that is

coordinated with the member/member representative, other caregivers as applicable, and

authorized by the MCO. All services provided, claimed, and billed must have documented

justification supporting medical necessity. Reimbursement is on a per hour basis and rounded to the

nearest quarter hour.

• Payment for SLT services is based on the negotiated rate through the MCO and is considered

payment in full. Providers of service have the responsibility to review and ensure the information

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on the prior authorization for their services is correct. If the provider identifies an error, they must

contact the MCO immediately to have the error corrected.

• SLT services must abide by all Federal, State, HSD policies and procedures regarding billable and

non-billable items.

• Billable hours are as follows:

o Face-to-face activities described in the Scope of Service;

o Maximum of eight hours for an initial comprehensive individual assessment;

o Maximum of eight hours to develop an initial comprehensive therapy plan;

o Attendance and/or telephone conference call to participate in IDT meetings;

o Annual maximum of six hours to complete progress reports and/or to revise annual plan;

o Annual maximum of eight hours to arrange assistive technology development;

o Reimbursement is on a unit rate per hour and rounded to the nearest quarter hour; and

o Training on member specific issues is reimbursable, general training requirements are an

administrative cost and not billable.

Limits or Exclusions

• HSD/MAD does not consider the following to be professional SLT services and will not authorize

payment for the following non-billable activities:

o Performing specific errands for the individual and/or family that are not program specific;

o Friendly visiting;

o Financial brokerage services, handling of member finances, or, preparation of legal documents;

o Time spent on paperwork or travel that is administrative for the provider;

o Transportation of members;

o Pick up and/or delivery of commodities; and

o Other non-Medicaid reimbursable activities.

• SLT providers must ensure all insurance records are maintained correctly.

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Services, Service Codes and Applicable Units of Service

SERVICE TYPE

CODE

UNIT INCREMENTS

1 UNIT =

Adult Day Health

S5100

15 minutes

Assisted Living

T2031

Day

Community Transition Services

T2038

Per service

Emergency Response

S5161

Month

Emergency Response High Need

S5161 U1

Month

Environmental Modifications

S5165

1 unit per project

Behavior Support Consultation

H2019

15 minutes

Behavior Support Consultation, Clinic Based

H2019TT

15 minutes

Employment Supports

H2024

Day

Home Health Aide

S9122

Hour

Nutritional Counseling

S9470

Hour

Personal Care-Consumer Directed

99509

Hour

Personal Care-Consumer Delegated

T1019

15 minutes

Personal Care-Directed training

S5110

15 minutes

Personal Care-Directed-Administrative Fee

G9006

1 unit + 1 month

Personal Care-Directed Advertisement Reimbursement Fee

G9012

1 Advertisement

Private Duty Nursing for Adults – RN

T1002

15 minutes

Private Duty Nursing for Adults – LPN

T1003

15 minutes

Respite RN

T1002 U1

15 minutes

Private Duty Nursing for Adults – LPN

T1003 U1

15 minutes

Respite

99509 U1

Hour

Physical Therapy for Adults

G0151

15 minutes

Occupational Therapy for Adults

G0152

15 minutes

Speech Language Therapy for Adults

G0153

15 minutes

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Personal Care Services (PCS) Consumer Directed Model Code Definitions

Personal Care

Consumer-Directed

99509

Hour

The rate for ongoing attendant services. The rate includes

both the employee’s and the employer’s share of Social

Security withholding and the cost for worker’s

compensation insurance. The maximum number of hours

billable is determined by the authorization issued by the

MCO which must be approved by the MCO Medicaid

Utilization Review Department.

Personal Care

Consumer-Directed

Training

S5110

15 minutes

The rate for training provided to the consumer or their

attendant at the request of the consumer. There is an

annual maximum of eight (8) hours of training allowed per

consumer.

Personal Care

Consumer-Directed

Reimbursement Fee

G9012

1 unit = 1

The maximum allowable rate for advertising. Consumers

are reimbursed for up to two (2) advertisements per year if

seeking a new Personal Care Attendant. If the billed

amount exceeds the maximum allowable rate, the billed

amount will be reduced to the maximum allowable

rate. The advertising reimbursement is allowed only for

actual and necessary advertising. Documentation is

required in the case file.

Personal Care

Consumer-Directed

Administrative Fee

G9006

1 unit = 1 month

The rate for fiscal intermediary tasks such as processing

payroll for the consumer’s Personal Care Attendants,

producing reports required by the Medical Assistance

Division, processing claims for Consumer-Directed Personal

Care services (including Income Tax and Social Security

withholding) and submitting billings to the MCO.

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9. Self-Directed Community Benefits (SDCB)

9.1. Purpose

The SDCB is intended to provide a community-based alternative to institutional care that facilitates

greater member choice, direction and control over covered services and supports. For this section of the

Manual, the terms “member”, “care plan”, “services” and “providers” refer to SDCB.

HCBS shall meet the following standards:

• Are integrated and support full access of individuals receiving Medicaid HCBS to the greater

community, including opportunities to seek employment, and work in competitive integrated

settings, engage in community life, control personal resources, and receive services in the

community, to the same degree of access as individuals not receiving Medicaid HCBS;

• Are selected by the individual from among setting options including non-disability specific settings.

The setting options are identified and documented in the person-centered service plan and are

based on the individual’s needs and preferences;

• Ensure an individual’s rights of privacy, dignity and respect, and freedom from coercion and

restraint;

• Optimize, but do not regiment, individual initiative, autonomy, and independence in making life

choices, including but not limited to, daily activities, physical environment, and with whom to

interact; and

• Facilitate individual choice regarding services and supports, and who provides them.

CMS will take the following factors into account when determining whether a setting may have the

effect of isolating individuals receiving Medicaid HCBS form the broader community of individuals not

receiving HCBS:

• Due to the design or model of service provision in the setting, individuals have limited, if

any, opportunities for interaction in and with the broader community, including with

individuals not receiving Medicaid funded HCBS. Opportunities as well as identified

supports to provide access to and participation in the broader community, should be

reflected in both the individuals’ person-centered service plans and policies and

practices of the setting in accordance with 42 CFR 441.301(c)(1)(3) and (4)(vi)(F), 42 CFR

441.530(a)(1)(vi)(F) and 441.540, and 42 CFR 441.710(a)(1)(vi)(F) and 441.725;

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• The setting restricts beneficiary choice to receive services or to engage in activities

outside of the setting; or

• The setting is physically located separate and apart from the broader community and

does not facilitate beneficiary opportunity to access the broader community and

participate in community services, consistent with the beneficiary’s person-centered

service plan.

9.2. Guiding Principles

All members:

• Have value and potential;

• Will be viewed in terms of their abilities;

• Have the right to participate and be fully included in their communities; and

• Have the right to live, work, learn, and receive services and supports to meet their individual needs,

in the most integrated settings possible within their community.

9.3. Philosophy of Self Direction

Self-direction is a tool that leads to self-determination, through which members can have greater

control over their lives and have more freedom to lead a meaningful life in the community. Within the

context of SDCB, self-direction means members choose which covered services they need, as identified

in the most recent CNA. Members also decide when, where and how those SDCB covered services will

be provided and who they want to provide them. Members decide who they want to assist them with

planning and managing their SDCB covered services within a managed care environment. Self-direction

means members have more choice, control, flexibility, freedom and responsibility in directing their CBs.

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9.4. Definitions

1. Authorized Representative (AR): The AR is an individual designated to represent and act on the

member’s behalf. The member or AR must provide formal documentation authorizing the named

individual or individuals to access the identified case information for a specified purpose and time

frame. An AR may be an attorney representing a person or household, a person acting under the

authority of a valid power of attorney, a guardian, or any other individual or individuals designated

in writing by the eligible recipient or member.

2. Centers for Medicare and Medicaid Services (CMS): Federal agency within the United States

Department of Health and Human Services that works in partnership with the states to administer

Medicaid. CMS must approve all Medicaid programs.

3. Electronic Visit Verification (EVV): EVV is a computer-based system that electronically verifies the

occurrence of authorized personal care service visits by electronically documenting the precise time

and location where a service delivery visit begins and ends. For SDCB, EVV will be implemented

according to federal requirements and timelines.

4. Employer of Record (EOR): Individual responsible for directing the work of SDCB employees by

recruiting, hiring, training, supervising and terminating employees, and ensuring payment to

employees and vendors.

5. Financial Management Agency (FMA): Contracted with each Centennial Care MCO and helps the

member implement the approved SDCB Care Plan by receiving and processing payment requests for

the member’s employees and vendors, tracking the SDCB expenditures and credentialing the SDCB

employees and vendors.

6. FOCoSonline: The web-based system used by the SDCB FMA for receiving and processing SDCB

payment requests. The FOCoSonline system is also used by members, Care Coordinators, and

Support Brokers to develop and submit SDCB care plan/budget requests for MCO/UR review, and to

monitor utilization and spending throughout the SDCB care plan year.

7. Human Services Department (HSD): Designated by CMS as the Medicaid administering agency in

New Mexico. HSD is also responsible for operating the SDCB HCBS for populations that meet the NF

LOC (disabled & elderly, brain injury, and AIDS).

8. Legally Responsible Individual (LRI): A person who has a duty under State law to care for another

person. This category typically includes: the parent (biological or adoptive) of a minor child; the

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guardian of a minor child who must provide care to the child; or the spouse of a member. Payment

may not be made to a LRI for the provision of personal care or similar services that the LRI would

ordinarily perform or be responsible to perform on behalf of a member. Exceptions to this

prohibition may be made under extraordinary circumstances specified by the State, utilizing

documentation specified by the State and only after approval by the appropriate MCO.

9. MCO/UR: Provides services related to medical eligibility determination and re-determination, and

NF LOC for members. The MCO also performs UM duties, review and approval or denial of each

individual services or related goods requested in the SDCB care plan/budget.

10. Quality Assurance and Quality Improvement (QA/QI): Processes utilized by state and Federal

governments, programs and providers whereby appropriate oversight and monitoring of CB

assurances and other measures provide information about the health and welfare of members and

the delivery of appropriate services. This information is then collected, analyzed and used to

improve services and outcomes and to meet requirements by state and Federal agencies. Quality

plans, systems and processes are designed and implemented to maintain continuous QI.

11. Reconsideration: Members who disagree with an adverse decision made by the MCO/UR may

submit a written request through a Care Coordinator/Support Broker to the MCO/UR for a

reconsideration of the adverse decision. These requests must include new, additional information

that is different from, or expands on, the information submitted with the initial request.

12. SDCB: Is a component of the State’s 1115 Medicaid Managed Care waiver which allows eligible

members meeting NF LOC the option to access SDCB Medicaid funds, using the essential elements

of person-centered planning, individualized budgeting, member protections, and QA/QI. Members

have choices (among the state-determined SDCB services and related goods) in identifying,

accessing and managing the services and related goods needed to meet their personal goals.

13. SDCB Budget: The maximum budget allotment available to an eligible member, determined by

his/her established NF LOC, CNA, and the amount and type of services the member was receiving in

the ABCB. Based on this maximum amount, the eligible member will develop a SDCB care plan to

meet his/her assessed functional, medical and habilitative needs to enable that member to remain

in the community.

14. SDCB Care Plan: A plan that includes approved SDCB services of the SDCB member’s choice; the

projected cost, frequency and duration of services and related goods; the type of provider who will

furnish each service or related good; other services and related goods to be used by the member.

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Each SDCB care plan shall include a backup plan which lists who the member will contact if regularly

scheduled employees or service providers are unable to report to work. The SDCB care plan is

mandatory for all SDCB members and must be processed through the FOCoSonline or other state

approved system.

15. SDCB Member: An individual who meets the medical and financial eligibility and is approved to

receive services through the SDCB after receiving services in the ABCB for a minimum of 120

calendar days.

16. Support Broker (SB): An individual who provides support to members and assists the member (or

the member’s family or representative, as appropriate) in arranging for, directing and managing

services and supports as well as developing, implementing and monitoring the SDCB care plan and

budget. Individual Support Brokers work for MCO contracted Support Broker agencies or may be

directly employed by an MCO.

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9.5. SDCB Member Rights

SDCB member has the right to:

• Decide where and with whom to live;

• Choose his/her own work or productive activity;

• Choose how to establish community and personal relationships;

• Make decisions regarding his/her own support, based upon informed choice;

• Be respected and supported during the decision-making process and in the decisions made;

• Recruit, hire, train, schedule, supervise and terminate SDCB service providers, as necessary;

• Receive training, resources and information related to SDCB in a format that meets the ADA

requirements;

• Have the right to appeal denial decisions through the MCO appeals and State fair hearing processes;

• Transfer to programs that are not self-directed; and

• Receive culturally competent services.

9.6. SDCB Member Responsibilities

SDCB members have certain responsibilities in order to participate in the program. Failure to comply

with these responsibilities or other program rules and policies can result in an involuntary termination

from the SDCB.

The most basic responsibility of each member is to maintain his/her financial and medical eligibility to

remain in the SDCB. This includes completing the required documentation to determine initial and

annual financial eligibility and participating in the initial and annual CNA conducted by the MCO. The

Care Coordinator and Support Broker may assist with the application and recertification process as

needed.

Ongoing SDCB member responsibilities include:

• Comply with the rules and policies that govern the SDCB;

• Maintain an open and collaborative relationship with the Care Coordinator and Support Broker, and

work together to determine support needs related to the activities of self-direction, develop an

appropriate SDCB care plan/budget request, receive necessary assistance with carrying out the

approved SDCB care plan/budget, and with documenting service delivery;

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• Communicate with the Support Broker at least once a month, either in person or by phone, and

meet with the Support Broker in-person at least once every three months. Report concerns or

problems with any part of SDCB to the Support Broker or Care Coordinator;

• Use SDCB funds appropriately by only requesting services and related goods covered by the SDCB

and only purchasing services and related goods after they have been approved by the MCO;

• Comply with the approved SDCB care plan and not spend more than the authorized budget;

• Work with the Care Coordinator by attending scheduled meetings and assessments, in the

member’s home as required, and providing documentation as requested;

• Respond to requests for additional documentation and information from the Care Coordinator,

Support Broker, FMA, and the MCO within the required deadlines;

• Report to the local ISD office, within 10 business days, any change in circumstances, including, but

not limited to, a change in address or hospitalization, which may affect eligibility for the program.

Changes in address or other contact information must also be reported to the Care Coordinator,

Support Broker and the FMA within 10 calendar days;

• Report to the Care Coordinator and Support Broker if hospitalized for more than three consecutive

nights so that a new appropriate LOC or CNA can be conducted; and

• Communicate with SDCB service providers, State contractors and State personnel in a respectful,

non-abusive and non-threatening manner.

Member/employer of record (EOR) Responsibilities: Every member must have an EOR who is

responsible for directing the work of SDCB employees and ensuring accurate and timely employee and

vendor payment requests are sent to the FMA for processing. The EOR must authorize by signing, either

electronically or on paper, all invoices and timesheets for his/her employees and vendors. A member

may be his/her own EOR unless the member is a minor or has a guardianship or conservatorship in place

that precludes the individual from exercising control over financial matters. A designated EOR may not

be an employee of the member. Members may also designate an individual of their choice to serve as

their EOR, subject to the EOR meeting the qualifications specified in the SDCB rules and policies. The

Care Coordinator completes an EOR self-assessment at least annually with the member to determine if

the member requires assistance in fulfilling the EOR responsibilities. If the EOR self-assessment

demonstrates the member is not able to be his/her own EOR, and the member does not designate a

qualified individual to serve as the EOR, the member shall not be allowed to transfer to SDCB until the

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member designates a suitable EOR. If the member was already his/her own EOR, and based on the

results of the self-assessment, the Care Coordinator determines that the member requires assistance to

direct his or her services, the Care Coordinator shall inform the member that he or she will need to

designate an EOR to assume the self-direction functions on their behalf. A member’s failure to follow

this direction may be cause for involuntary termination from the SDCB program.

An EOR is responsible for recruiting, hiring, training, supervising and terminating employees, as

necessary. The EOR will establish work schedules and tasks and provide relevant training. The EOR will

keep track of SDCB budget amounts spent on paying employees and for approved services and related

goods. EORs authorize the payment of timesheets and invoices by the FMA. EORs must use the FMA

electronic timesheet system, unless granted an exception by the MCO. EORs must also ensure that their

self-directed personal care and respite providers use the State approved EVV system as required. An EOR

cannot be paid for any services utilized by the member for whom he or she is the EOR and the EOR

cannot be paid for performing the EOR functions. An individual may serve as an EOR for more than one

SDCB member.

The SDCB member/EOR responsibilities include:

• Arranging for the delivery of SDCB services, supports and related goods as approved in the SDCB

care plan;

• Verifying and attesting that employees meet the minimum qualifications for employment as

required by the SDCB;

• Orienting, training, and directing SDCB employees in providing the services that are described and

authorized in the member’s SDCB care plan;

• Establishing a mutually agreeable schedule for employees’ services in writing and providing fair

notice of changes in the employee’s work schedule in the event of unforeseen circumstances or

emergencies;

• Submitting all necessary and required documents to the FMA. Documents must be completed and

provided to the FMA according to the timelines and rules established by the State. Documents

include, but are not limited to, vendor and employee agreements, vendor information forms, CBC

forms, time-sheets, payment request forms (PRFs) and invoices, updated employee information, and

other documentation needed by the FMA to process timely and accurate payment to SDCB

providers;

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• Agreeing that SDCB employees may not begin work until all materials necessary for a CBC have been

received by the FMA and the employee has successfully passed the COR background check and the

National Sex Offender Registry;

• Agreeing to select or employ the employee on an interim (temporary) basis until a final CBC has

been successfully completed, for those crimes determined to be disqualifying convictions as stated

in NMSA 1978, Section 29-17-3. The EOR discusses this with the employee and reserves the right to

dismiss the employee based on the results of the CBC;

• Providing fair notice of changes in the employee’s work schedule in the event of unforeseen

circumstances or emergencies;

• Reviewing and approving/denying completed employee timesheets in order to pay employees

according to the FMA predetermined payroll schedule. Net wages are gross earnings calculated

according to the employee’s pay rate, minus payroll deductions for the employee’s share of

applicable State, Federal, and local payroll withholdings;

• Ensuring employees are not signing or sending in their own timesheets;

• Reporting any incidents of abuse, neglect or exploitation by any employee or other service provider

to the Support Broker and/or Care Coordinator;

• Maintaining SDCB employee and service records and documentation in accordance with SDCB rules

and policies, and Federal and state employment rules;

• As the common-law employer, fully cooperating with the New Mexico Department of Workforce

Solutions (DWS) in any investigations or other matters related to his/her SDCB employees;

• Working with the FMA and Care Coordinator on payment issues;

• Fully cooperating with the State’s worker’s compensation carrier. Responsibilities include reporting

claims and providing information to New Mexico Mutual;

• Meeting Federal employer requirements, such as completing and maintaining a Federal I-9 form for

each employee as required by law; and

• When necessary, requesting assistance from the Support Broker and/or Care Coordinator with any

of these SDCB responsibilities.

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9.7. SDCB Supports

Important resources of support and direction for members are the MCO, the Support Broker and the

FMA. The MCO determines initial and ongoing medical eligibility, reviews and authorizes the SDCB care

plan/budget, and provides care coordination and support to the member to ensure successful

implementation of the care plan. The Support Broker provides support to the SDCB member (or the

member’s family/representative, as appropriate) in arranging for, directing, and managing SDCB services

and supports as well as developing, implementing, and monitoring the care plan and budget. The FMA

acts as the intermediary between the member and the Medicaid payment system and assists the

member or the EOR with employer-related responsibilities.

MCO

The MCO provides services related to medical eligibility determination and re-determination, and

determines the NF LOC for SDCB members. The MCO also performs UM duties, including review and

approval or denial of each individual care plan. All SDCB members have an MCO Care Coordinator and a

Support Broker. The Care Coordinator and Support Broker assist the member with virtually every aspect

of the SDCB. The Support Broker is instrumental in developing the SDCB care plan and provides an

additional layer of assistance to ensure successful implementation of the SDCB care plan.

Care Coordinator

The Care Coordinator is responsible for managing the member’s acute care, BH care, LTC, and HCBS. In

SDCB, the Care Coordinator is primarily responsible for coordinating all aspects of the member’s care,

determining the SDCB budget, and submitting the care plan to the MCO for review and approval/denial.

Care Coordinator related assistance includes, but is not limited to:

• Understanding SDCB member and EOR roles and responsibilities;

• Identifying resources outside the SDCB, including natural and informal supports, that may assist in

meeting the member’s needs;

• Understanding the array of SDCB covered services, supports, and related goods;

• Determining and assigning the annual budget for the SDCB member, based on the CNA, to address

the home- and community-based needs of the SDCB member in accordance with the requirements

stated in the Agreement and the member’s CB;

• Providing the Support Broker with the current and all historical CNAs including the assessor’s

individual specific health and safety recommendations, and the calculations used to determine the

SDCB budget;

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• Monitoring utilization of SDCB services and related goods on a regular basis;

• Assisting the EOR, and working with the FMA; on payment issues;

• Conducting employer-related activities such as completing the EOR self-assessment with the

member and informing the FMA of the designated EOR;

• Identifying and resolving issues related to the implementation of the SDCB care plan/budget;

• Assisting the SDCB member with QA activities to ensure implementation of the member’s SDCB care

plan/budget, and utilization of the authorized budget;

• Recognizing and reporting critical incidents, including abuse, neglect, exploitation, emergency

services, law enforcement involvement, and environmental hazards;

• Monitoring the quality of services provided by Support Brokers;

• Assisting the member with Support Broker changes; and

• Working with the member to provide the necessary assistance for successful SDCB implementation.

Support Broker

Support Broker services are direct services intended to educate, guide, and assist the SDCB member to

make informed planning decisions about SDCB services and supports and to assist the member with QA

related to the SDCB care plan. This leads to the development of a Care Plan that is based on the

member’s assessed needs and is in accordance with 8.308.12 NMAC, and the Manual.

Support Broker services help the SDCB member to identify supports, services and related goods that

meet his/her needs as identified in the most recent CNA and are specific to the member’s disability or

qualifying condition and help prevent institutionalization. Support Broker services provide a level of

support to SDCB members that are unique to their individual needs in order to maximize their ability to

self-direct.

• The extent of assistance is based upon the individual member’s needs, and includes, but is not

limited to, providing help and guidance to:

o Educate members on how to use self-directed supports and services and provide information on

program changes or updates;

o Review, monitor and document progress of the member’s care plan;

o Assist in managing budget expenditures and complete and submit care plan revisions;

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o Assist with EOR functions including, but not limited to recruiting, hiring and supervising SDCB

providers;

o Assist with developing job descriptions for the SDCB direct support caregivers;

o Assist with completing forms related to SDCB employees;

o Assist with approving timesheets and purchase orders or invoices for related goods, obtaining

quotes for services and related goods as well as identifying and negotiating with vendors;

o Assist with problem solving employee and vendor payment issues with the FMA and other

relevant parties;

o Facilitate resolution of any disputes regarding payment to providers for services rendered;

o Develop the care plan based on the SDCB budget amount determined by the annual CNA;

o Assist in completing all documentation required by the FMA; and

o Assist with EVV functions including device registration and entering location information.

• Support Broker services begin with the enrollment of the member in SDCB and continue throughout

the member’s participation in SDCB. The Support Broker shall:

o Conduct a transition meeting, including the transfer of program information prior to the SDCB

enrollment meeting, for those members transitioning from the ABCB;

o Assist members to transition from/to ABCB/SDCB.

o Provide the SDCB member with information, support and assistance during the annual Medicaid

eligibility processes, including the annual CNA and the annual medical/financial eligibility

processes;

o Assist existing members with annual LOC requirements within 120 calendar days prior to the

expiration of the LOC; and

o Schedule member enrollment meetings within five business days of notification and Support

Broker agency selection. The actual enrollment meeting should be conducted within 30 calendar

days. Enrollment activities include but are not limited to:

▪ Ensure the member has received and reviewed the SDCB Rules and the Manual and provide

responses to their questions and/or concerns;

▪ General overview of the SDCB including key agencies, their responsibilities and contact

information;

▪ Discuss the annual Medicaid eligibility requirements and offer assistance in completing

these requirements as needed;

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▪ Discuss and review SDCB member roles and responsibilities;

▪ Discuss and review the EOR roles and responsibilities;

▪ Discuss and review the processes for hiring SDCB employees and contractors and required

paperwork;

▪ Discuss and review the requirements, process and paperwork for hiring LRIs as employees;

▪ Discuss and review the background check and other credentialing requirements for SDCB

employees and vendors;

▪ Referral for accessing training for the FOCoSonline system; and to obtain information on the

FMA;

▪ Discuss and review the EVV system that personal care and respite provider(s) will be

required to use;

o Schedule the date for SDCB care plan meeting within 10 business days of the SDCB enrollment

meeting;

o Provide information on the SDCB care plan including covered services and related goods, and

community resources available;

o Assist the members in utilizing all program assessments including the CNA, to develop each

SDCB care plan;

o Educate members regarding SDCB covered services, supports and related goods;

o Assist member to identify resources outside SDCB that may assist in meeting his/her needs as

identified in the CNA;

o Assist the member with the application for LRI as employee process; submit the application to

the MCO/UR;

o Assist members with the environmental modification process;

o Serve as an advocate for the SDCB member, as needed, to enhance his/her opportunity to be

successful in the SDCB;

o Assist the member with reconsiderations of services or related goods denied by the MCO/UR,

submit documentations as required, and participate in MCO appeals process and State Fair

Hearings as requested by the MCO, SDCB member or state;

o Assist the member with QA activities to ensure implementation of the member’s SDCB care

plan, and utilization of the SDCB annual budget;

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o Assist members to transition to another Support Broker agency when requested. Support Broker

transitions should occur within 30 calendar days of SDCB member’s written request, but may

occur sooner based on the needs of the SDCB member. Transition from one Support Broker

agency to another can only occur at the first of the month. Support Broker agency transitions

may not occur if there are less than 120 days remaining in the current LOC;

o Assist members to identify and resolve issues related to the implementation of the SDCB care

plan; and

o Assist the member, employee(s) and EOR in utilizing the EVV system, including but not limited

to:

▪ Registering the device (tablet, computer or mobile device) to be utilized for EVV;

▪ Collaborating with MCO Care Coordination and the member/EOR to resolve any

time entry, timecard, or payment issues;

▪ Understanding and agreeing to all roles and responsibilities of the EVV system;

▪ Training and assisting member/EOR and employee(s) on the EVV system to

include:

• Employee and EOR device enrollment

• Employee initial log in

• Employer Web log in

• Alternate Interactive Voice Response (IVR) phone numbers

• Updating alternate care locations

• Support Brokers must ensure the SDCB care plan for each member is submitted in the appropriate

format as prescribed by the state and MCOs, utilizing the FOCoSonline system. The care plan in

FOCoSonline shall include the following:

o The requested services and supports that are covered by the SDCB, and necessary to address

the needs of the member as determined through the CNA and person-centered planning

process;

o The purpose for the requested services, expected outcomes, and methods for monitoring

progress must be clearly and specifically identified and addressed;

o Clear, specific and accurate calculation of the employee/vendor reimbursement rate including

all local and/or Federal taxes using the calculator in FOCoSonline; and

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o The quality indicators, identified by the member, for the services and supports provided through

the SDCB. SDCB care plan revisions shall be completed and submitted as needed, in the format

as prescribed by the state. No more than one revision is allowed to be submitted at any given

time. The annual SDCB care plan must be submitted to the Care Coordinator and MCO/UR at

least 30 calendar days prior to the expiration of the current SDCB plan so that sufficient time is

afforded for MCO/UR review. A copy of the final approved SDCB care plan and budget

documents must be provided to each SDCB member.

• Support Brokers will contact the SDCB member in person or by telephone at least monthly for a

routine follow-up. Support Brokers will meet in person with the member at least once per quarter. It

is mandatory that a minimum of one visit per SDCB care plan year is to be conducted in the

member’s home. Support Brokers will, at a minimum:

o Review spending patterns;

o Review and document progress of care plan/budget implementation;

o Document the usage and effectiveness of the SDCB backup plan; and

o Document the purchase of related goods.

The quarterly visits are for the following purposes:

o Review and document progress on implementation of the SDCB care plan;

o Review and document any usage and the effectiveness of the 24-hour backup plan and update

the backup plan as necessary;

o Review SDCB care plan and budget spending patterns (over and underutilization);

o Review and document the SDCB member’s access to SDCB related goods requested and

approved in the SDCB care plan;

o Review any incidents or events that have impacted the SDCB member’s health and welfare or

ability to fully access and utilize service(s) as identified and approved in the SDCB care plan; and

o Identify other concerns or challenges as noted by the member/representative/EOR.

Administrative Requirements

Support Broker services may be provided by direct MCO personnel or by Support Broker agencies

subcontracted by the MCO. SDCB members may choose to work with one of their MCO’s contracted

Support Broker agencies that is providing Support Broker services in their region. If an MCO employs

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MCO personnel to provide Support Broker services, the same qualifications and criteria that are used for

Support Broker agencies also apply to the MCO personnel.

The Support Broker agency shall comply with all applicable Federal and State rules, all policies and

procedures governing Support Broker services, all terms of their provider agreement and shall meet all

of the following requirements, as applicable:

• Have a current business license issued by the state, county, or city government as required;

• Maintain financial solvency;

• Ensure all employees providing Support Broker services under this standard attend all

State-required orientation and trainings and demonstrate knowledge of and competence with the

SDCB rules, policies and procedures, philosophy of self-direction, financial management processes

and responsibilities, CNA, person-centered planning and SDCB care plan development, and adhere

to all other training requirements as specified by the State;

• Ensure all employees are trained and competent in the use of the FMA and FOCoSonline system;

• Ensure all employees providing services under this scope of service and all other staff are trained on

how to identify and where to report critical incidents, abuse, neglect and exploitation; and

• Ensure compliance with the Caregivers Criminal History Screening Requirements (7.1.9 NMAC) for all

employees.

The Support Broker agency shall develop a quality management plan to ensure compliance with

regulatory and program requirements and to identify opportunities for continuous QI.

The Support Broker agency shall ensure that SDCB members have access to their Support Broker. This

requirement includes, but is not limited to the following:

• The Support Broker agency must maintain a presence in each region for which they are providing

services;

• The Support Broker agency must maintain a consistent way (for example, phone, pager, email, and

fax) for the SDCB member to contact the Support Broker provider during typical business hours

which are 8:00 a.m. to 5:00 p.m. Monday through Friday;

• The Support Broker agency must maintain a consistent way (for example phone, pager, email, and

fax) for the SDCB member to contact the Support Broker provider during non-business hours: prior

to 8:00 a.m. and after 5:00 p.m. MST on weekdays and on weekends and for emergency purposes;

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• The Support Broker agency must provide a location to conduct confidential meetings with SDCB

members when it is not possible to do so in the SDCB member’s home. This location must be

convenient for the SDCB member and compliant with the ADA;

• The Support Broker agency must maintain an operational fax machine at all times;

• The Support Broker agency must maintain an operational email; address, internet access, and the

necessary technology to access SDCB related systems;

• The Support Broker agency shall maintain a current local/state community resource manual;

• The Support Broker agency shall adhere to Medicaid General Provider policies 8.302.1.;

• The Support Broker agency shall ensure the development and implementation of a written

grievance procedure in compliance with 8.349.2.11 NMAC;

• The Support Broker agency shall meet all of the qualifications set forth in 8.304.12 NMAC; and/or

• The Support Broker agency shall maintain HIPAA compliant primary records for each member

including, but not limited to:

o Current and historical SDCB care plan and budget;

o Contact log that documents all communication with the SDCB member;

o Completed/signed quarterly visit form(s);

o MCO/UR documentation of approvals/denials, including SDCB care plan and revision requests;

o MCO/UR correspondence; (requests for additional information, etc.);

o Copy of current and all historical CNAs including the assessor’s individual specific health and

safety recommendations;

o Notifications of medical and financial eligibility;

o SDCB budget utilization reports from the FMA;

o Environmental modification approvals/denials;

o LRI approvals/denials;

o Documentation of SDCB member and employee incident management training;

o Copy of legal guardianship or representative papers and other pertinent legal designations;

o Copy of the approval form for the AR and/or AA; and

o Copies of completed EOR self-assessments.

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Support Broker Qualifications

Support Broker agencies shall ensure that all individuals providing Support Broker services meet the

criteria specified in this section. Support Broker providers shall:

• Be at least 18 years of age; and

• Possess a minimum of a Bachelor’s degree in social work, psychology, human services, counseling,

nursing, special education or a closely related field; or

• Have one year of supervised experience working with seniors and/or people living with disabilities;

• Have a minimum of six years of direct experience related to the delivery of social services to seniors

and/or people living with disabilities;

• Complete all required SDCB orientation and training courses; and

• Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section 29-17-2 et

seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978, Section 27-7a-1 et seq.

and 8.11.6 NMAC; and the National Sex Offender Registry.

Conflict of Interest

The Support Broker agency may not provide any other direct services for SDCB members that have an

approved SDCB care plan and are actively receiving services in the SDCB. The Support Broker agency may

not employ, as a Support Broker, any immediate family member or guardian of a member in the SDCB

that is served by the Support Broker agency.

Critical Incident Management Responsibilities and Reporting Requirements

All incident reports for the HCBS and BH services population involving abuse, neglect, self-neglect,

exploitation, environmental hazard, law enforcement involvement, and emergency services, must be

reported to the member’s MCO, Support Broker and/or APS.

The Support Broker agency shall provide training to SDCB members related to recognizing and reporting

critical incidents. Critical incidents include: abuse, neglect, exploitation, emergency services, law

enforcement involvement, environmental hazards and member deaths. This SDCB member training shall

also include reporting procedures for SDCB employees, members/member representatives, and other

designated individuals. Please refer to the Critical Incident Management Responsibilities for

requirements.

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The Support Broker agency will also maintain documentation that each SDCB member has been trained

on the critical incident reporting process. This member training shall include reporting procedures for

SDCB members, employees, member representative, and/or other designated individuals. The Support

Broker agency shall report incidents of abuse, neglect and/or exploitation as directed by the State.

The Support Broker agency will maintain a critical incident management system to identify, report, and

address critical incidents. The Support Broker is responsible for follow-up and assisting the individual to

help ensure health and safety when a critical incident has occurred.

Financial Management Agent

The FMA is under contract with the MCOs to provide payment for services and related goods which are

approved on the SDCB care plan. The FMA is responsible for providing the following services in the

SDCB:

• Assure SDCB compliance with state and Federal employment and IRS requirements;

• Assist each member/EOR to set up a unique EIN if they intend to hire employees;

• Answer member inquiries, solve related problems, and offer periodic trainings for members and

their representatives on how to handle the SDCB billing and invoicing processes;

• Provide all members with necessary documents, instructions and guidelines;

• Collect all documentation necessary to verify that SDCB providers and vendors have the

qualifications and credentials required by the SDCB rules;

• Collect all documentation necessary to support the member’s specific arrangements with each

employee and vendor, including employment agreement forms and vendor agreement forms;

• Successfully complete criminal history and/or background investigations for prospective SDCB

service providers, pursuant to 7.1.9 NMAC and in accordance with 1978 Section 29-17-1 NMAC of

the Caregivers Criminal History Screening Act and the National Sex Offender Registry;

• Check the Department of Health Employee Abuse Registry, pursuant to 7.1.12 NMAC COR, to

determine whether prospective SDCB service providers or employees of members are included in

the registry. If a prospective SDCB provider or employee is listed in the Abuse Registry, that person

or vendor may not be employed by a SDCB member/EOR;

• Process and pay invoices for services and related goods that are approved in the member’s care

plan, when supported by required documentation;

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• Handle all payroll functions on behalf of members who hire direct service employees and other

support personnel, including collecting and processing timesheets of support workers, processing

payroll, withholding, filing and payment of applicable Federal, State and local employment-related

taxes and insurances;

• Track and report on SDCB employee payment disbursements and balances of member funds,

including providing the member and his/her Care Coordinator/Support Broker with a monthly report

of expenditures and budget status; and

• Report any concerns related to the health and safety of a member or that the member is not

following the approved SDCB care plan/budget to the Care Coordinator and/or Support Broker, and

HSD/MAD, as appropriate.

FOCoSonline

In addition to the above functions, the FMA operates FOCoSonline. FOCoSonline is a web-based system

that is used for FMA functions such as housing the SDCB care plan, noting the annual SDCB budget,

tracking the credentialing status of employees and vendors, timesheet submission, payment processing

for employees and vendors, and tracking the SDCB care plan/budget expenditures.

FOCoSonline is also used by SDCB members/EORs, Support Brokers and Care Coordinators to develop

and submit a SDCB care plan for MCO/UR review and approval/denial.

The MCO/UR also uses FOCoSonline to receive SDCB care plan/budget requests and request additional

information from the SDCB member and Care Coordinator/Support Broker, and to indicate what SDCB

services, supports and related goods have been approved or denied.

The FMA will provide SDCB members/EORs, Care Coordinators and Support Brokers with training and

access for FOCoSonline, as well as on-going technical assistance and help with problem solving.

9.8. Planning and Budgeting for SDCB Covered Services

SDCB Care Plan Development Processes

The SDCB care plan development process starts with person-centered planning. In person-centered

planning, the SDCB care plan must revolve around the individual SDCB member and reflect his/her

chosen lifestyle, cultural, functional, and social needs for successful community living. The goal of the

SDCB care plan development process is for the SDCB member to achieve a meaningful life in the

community, as defined by the SDCB member. Upon enrollment in SDCB and choosing his/her Support

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Broker agency, each SDCB member shall receive a SDCB budget amount, which is determined by the

Care Coordinator, based on the results of the NF LOC and the CNA. The SDCB budget amount is entered

into FOCoSonline by the Care Coordinator. The SDCB member will receive information and training from

the Care Coordinator and/or Support Broker about covered SDCB services and the requirements for the

content of the SDCB care plan.

The SDCB member is the leader in the development of the SDCB care plan. The member will take the

lead or be encouraged and supported to take the lead to the best of his/her abilities, to direct the

development of the SDCB care plan. If the member desires, he/she may include family members or

other individuals, including service workers or providers, in the SDCB care plan development process.

The SDCB care plan is entered into FOCoSonline by the Support Broker. The SDCB care plan is developed

one goal at a time. Each goal shall include a clear and complete explanation of the requested service(s)

or good(s) as defined in the service description, how they are related to the member’s condition and why

they are appropriate for the member.

In addition, each goal includes full details about each of the requested service(s) or good(s), including,

but not limited to: amount, frequency, cost or estimated cost, and rate of pay.

The SDCB care plan is developed by the member and the Support Broker. Once the SDCB care plan

request is complete and approved by the SDCB member, the Support Broker notifies the Care

Coordinator, via FOCoSonline, the member’s SDCB care plan is ready for review and submission into

FOCoSonline. After reviewing the SDCB care plan, the Care Coordinator will submit it in FOCoSonline to

the MCO/UR for review and approval or denial using FOCoSonline. Annual SDCB care plans shall be

submitted by the Care Coordinator to the MCO/UR no later than 30 calendar days prior to the end of the

current SDCB care plan/budget year. MCOs must provide the member with a written Notice of Action for

all MCO/UR decisions made in response to SDCB service related requests made by the SDCB member via

FOCoSonline.

SDCB Member’s Employer Authority

The SDCB EOR is the common-law employer of all SDCB service providers. The FMA serves as the

member’s agent in conducting payroll and other employer-related responsibilities that are required by

Federal and State law.

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SDCB Member Decision-Making Authority

Members shall have authority to do the following:

• Complete the employer paperwork to be submitted to the FMA;

• Determine the amount paid for SDCB services within the State’s approved limits (Range of Rates,

9.22.1);

• Schedule the provision of SDCB services;

• Specify service provider qualifications of the SDCB member’s choice, consistent with the

qualifications specified in the SDCB rules and the Manual;

• Specify how SDCB services are provided, consistent with the SDCB rules and the Manual;

• Identify potential SDCB service providers and vendors and refer them to the FMA for enrollment;

• Arrange to have potential SDCB service providers paid for the approved SDCB services by ensuring

that all proposed SDCB employees and service providers complete all FMA required paperwork,

including a CBC when necessary. Payment for approved SDCB services and related goods cannot be

made until all necessary and required paperwork is successfully completed and approved by the

FMA;

• Review, approve and submit SDCB provider timesheets to the FMA within established timeframes.

Timesheets must be submitted to the FMA electronically through FOCoSonline. The member’s MCO

shall approve an exception to the online timesheet requirement if the member is unable to submit

timesheets electronically. Failure to submit SDCB provider timesheets within the required

timeframes will result in SDCB providers not being paid in accordance with the employee payroll

schedule;

• Review, approve and submit payment requests, according to the SDCB care plan, for approved SDCB

services and related goods identified in the approved SDCB care plan. The SDCB member/EOR must

submit a PRF to the FMA and an invoice or receipt from a SDCB vendor for any item he/she has an

approved SDCB goal and budget to purchase; and

• Additionally, the SDCB members:

o Cannot/will not be reimbursed directly for any SDCB services, supports and/or related goods;

o Must follow the SDCB care plan as approved by the MCO/UR;

o Shall work with the FMA to have all potential SDCB employees, providers and vendors approved

and enrolled prior to delivery or provision of any SDCB service or good; and

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o Shall be accountable for the use of all SDCB funds.

9.9. SDCB Qualifications for all SDCB Employees, Independent Providers, Provider Agencies and Vendors

In order to be approved as a SDCB employee, an independent provider, a provider agency (excluding

Support Broker agencies, which are covered later in this document) or a vendor, each entity must meet

the general and service specific qualifications found in the SDCB rules and the Manual and submit an

employee agreement packet or vendor agreement packet, specific to the SDCB provider or vendor type,

for approval to the FMA.

SDCB providers must meet all Federal and State requirements for home- and community-based

providers. In order to be an authorized provider for SDCB, and receive payment for delivered services,

the potential provider must complete and sign an employee agreement or vendor agreement and

provide all required credentialing documents. The potential provider’s credentials must be verified by

the member/EOR and the FMA.

General qualifications for SDCB individual employees, independent providers, including non-licensed

homemaker/companion workers and provider agencies who are employed by a SDCB member/EOR to

provide direct services:

• Be at least 18 years of age;

• Be qualified to perform the service and demonstrate capacity to perform required tasks;

• Be able to communicate successfully with the SDCB member;

• Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section 29-17-2 et

seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978, Section 27-7a-1 et seq.

and 8.11.6 NMAC and the National Sex Offender Registry;

• Complete training on critical incident, abuse, neglect, and exploitation reporting;

• Complete member specific training; the evaluation of training needs is determined by the member

or his/her legal representative; the member is also responsible for providing and arranging for

employee training and supervising employee performance; training expenses for paid employees

cannot be paid for with the SDCB member’s annual budget;

• Meet any other service specific qualifications, as specified in the SDCB rules (8.308.12 NMAC); and

• Maintain documentation of services provided per the SDCB rules (8.308.12 NMAC).

General qualifications for SDCB vendors, including those providing professional services:

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• Be qualified to provide the service;

• Possess a valid business license, if applicable;

• If a professional provider, be required to follow the applicable licensing regulations set forth by the

profession; refer to the appropriate New Mexico Board of Licensure for information regarding

applicable licenses;

• If a Support Broker provider, meet all of the qualifications set forth in 8.308.12 NMAC;

• If a currently approved SDCB provider, be in good standing with the appropriate state agency;

• Meet any other service specific qualifications, as specified in the SDCB rules (8.308.12 NMAC); and

• Maintain documentation of services provided per the SDCB rules (8.308.12 NMAC).

General qualifications for LRIs who provide services:

• LRIs (e.g., the parent/guardian biological, legal or adoptive) of a minor child (under age 18) or the

guardian of a minor child, who must provide care to the child, or a spouse of a member, may be

hired and paid for the provision of SDCB-covered services (except Support Broker) under

extraordinary circumstances in order to assure the health and welfare of the member, to avoid

institutionalization and provided that the state is eligible to receive Federal financial participation;

• Extraordinary circumstances include the inability of the parent/legal guardian to find and retain

other qualified, suitable caregivers when the parent/guardian would otherwise be absent from the

home and, thus, the parent/guardian must stay at home to ensure the member’s health and safety.

The member may request that the LRI (parent/guardian or spouse) be allowed to be employed by

the member/EOR and provide services as approved in the member’s current SDCB care plan. The

request must include documentation showing all attempts to employ other available resources in

the member’s community, the challenges the member and/or providers encountered, and why the

member-chosen providers were unable to successfully provide the approved covered service as

approved in the SDCB care plan;

• LRIs may not be paid for any services that they would ordinarily perform in the household for

individuals of the same age who do not have a disability or chronic illness. This includes, but is not

limited to, transportation of minors to and from school, activities and events; and

• Requests to employ an LRI must be submitted in writing to the MCO. The request must be approved

or denied in writing by the appropriate MCO/UR staff member. The approval of an LRI must be

renewed annually, at the same time as the NF LOC and SDCB care plan.

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• Services provided by LRIs must:

o Meet the definition of a SDCB covered service and be specified in the member’s approved SDCB

care plan;

o Be provided by a SDCB member’s parent/guardian or spouse who meets the provider

qualifications and training standards specified in the SDCB rules and these service descriptions

and qualifications for that covered service; and

o Be paid at a rate that does not exceed the SDCB Range of Rates (9.22.1) for the specific service

the LRI is approved to provide and be approved by the MCO/UR.

9.10. SDCB Covered Services

All services are subject to the approval of the MCO/UR. Below is a list of SDCB covered services and

related goods for members in SDCB, followed by a detailed service description:

• Behavior Support Consultation Services;

• Customized Community Support;

• Emergency Response;

• Employment Supports;

• Environmental Modifications;

• HH Aide;

• Nutritional Counseling;

• Private Duty Nursing;

• Related Goods;

• Respite;

• Self-Directed Personal Care;

• Skilled Maintenance Therapy Services for Adults;

• Specialized Therapies; and

• Transportation (Non-Medical).

Descriptions for each of the above SDCB covered services are as follows.

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Behavior support consultation services

• Definition of Service

Behavior Support Consultation services consist of functional support assessments, treatment plan

development and training and support coordination for a SDCB member related to behaviors that

compromise a member’s quality of life. Behavior support consultation services are provided in an

integrated/natural setting or in a clinical setting.

• Scope of Services:

o Inform and guide the SDCB member, family, employees and/or vendors on understanding the

contributing factors to the SDCB member’s behavior;

o Identify support strategies to enhance functional capacities, adding to the provider’s

competency to predict, prevent and respond to interfering behavior and potentially reducing

interfering behaviors;

o Support effective implementation based on a functional assessment and subsequent SDCB care

plans;

o Collaborate with medical and ancillary therapies to promote coherent psychotherapeutic

medications; and

o Monitor and adapt support strategies based on the response of the SDCB member and his/her

family, employees and/or vendors.

• Behavior Support Consultant Qualifications – Individual:

o Provide a tax identification number;

o Maintain a member file within HIPAA guidelines to include:

▪ Member’s SDCB care plan;

▪ Reports as requested in the SDCB care plan;

▪ Contact notes; and

▪ Training roster(s).

o Have and maintain a current New Mexico license with the appropriate professional field

licensing body; current licensure may be any of the following:

▪ MD;

▪ Licensed clinical psychologist;

▪ Licensed psychologist associate (masters or PhD level);

▪ LISW or LMSW;

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▪ LPCC;

▪ Licensed professional counselor (LPC);

▪ Licensed psychiatric nurse;

▪ LMFT; or

▪ Licensed practicing art therapist (LPAT).

• Behavior Support Consultant Qualifications - Provider Agency

o Provide a tax identification number; and current business license issued by State, county or city

government, if required;

o Maintain a member file within HIPAA guidelines to include:

▪ Member’s SDCB care plan;

▪ Reports as requested in the SDCB care plan;

▪ Contact notes; and

▪ Training roster(s).

o Ensure therapists have and maintain a current New Mexico license with the appropriate

professional field licensing body; current licensure may be any of the following:

▪ MD;

▪ Licensed clinical psychologist;

▪ Licensed psychologist associate (masters or PhD level);

▪ LISW or LMSW;

▪ LPCC;

▪ LPC;

▪ MSN/RNSC;

▪ LMFT; or

▪ LPAT.

Customized Community Supports

• Definition of Service

o Customized community support services are designed to offer the SDCB member flexible

supports that are related to the member’s qualifying condition or disability. Customized

community supports may include participation in congregate community day programs and

centers that offer functional meaningful activities that assist with acquisition, retention, or

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improvement in self-help, socialization and adaptive skills. Customized community supports may

include adult day habilitation, adult day health and other day support models. Customized

community supports are provided in community day program facilities and centers and can take

place in non-institutional and non-residential settings.

o Customized community supports settings must be integrated and support full access of

individuals receiving Centennial Care CBs to the greater community, including opportunities to

seek employment, and work in competitive integrated settings, engage in community life,

control personal resources, and receive services in the community, with the same degree of

access as individuals not receiving Medicaid HCBS.

o These services are provided at least four or more hours per day one or more days per week as

specified in the member’s SDCB care plan. Customized community supports cannot duplicate

any other SDCB service.

• Scope of Services

o Customized Community Support services include, but are not limited to the following:

▪ Provide supports in congregate and community day programs that assist with the

acquisition, retention or improvement in self-help, socialization and adaptive skills;

▪ Adult day health services;

▪ Adult day habilitation services; and

▪ Other day support model services.

o Customized Community Supports Qualifications - Provider Agency:

▪ Possess a current business license, if applicable;

▪ Meet financial solvency;

▪ Adhere to training requirements;

▪ Maintain member records for each member within HIPAA compliance;

▪ Develop and adhere to a records management policy;

▪ Develop and adhere to QA rules and requirements;

▪ Adult day health provider agencies must be licensed by New Mexico DOH as an adult day

care facility pursuant to 7.13.2 NMAC; and

▪ Ensure all assigned staff meets the following qualifications:

• Be at least 18 years of age;

• Have at least one year of experience working with people with disabilities;

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• Be qualified to perform the service and demonstrate capacity to perform required tasks;

• Be able to communicate successfully with the member/member representative;

• Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section

29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978,

Section 27-7a-1 et seq. and 8.11.6 NMAC;

• Complete training on critical incident, abuse, neglect, and exploitation reporting;

• Complete member specific training; the evaluation of training needs is determined by

the member or his/her legal representative; member is also responsible for providing

and arranging for provider training and supervising provider performance; training

expenses for paid providers cannot be paid for with the SDCB member’s budget; and

• Meet any other service qualifications, as specified in the SDCB rules.

Emergency Response

• Definition of Service:

o Emergency Response Services provide an electronic device that enables a member to secure help

in an emergency at home and thereby avoid institutionalization. The member may also wear a

portable “help” button to allow for mobility. The system is connected to the member’s phone

and programmed to signal a response center when a “help” button is activated. The response

center is staffed by trained professionals.

• Scope of Services:

o Testing and maintaining equipment;

o Training SDCB members, caregivers and first responders on the use of the equipment;

o 24-hour monitoring for alarms;

o Checking systems monthly or more frequently if warranted (e.g., electrical outages, severe

weather); and

o Reporting member’s condition that may affect service delivery; and

o Initial set-up and installation of Emergency Response Service devices is not a covered service; see

the service description for environmental modification for allowance of the initial set-up and

installation.

• Emergency Response Qualifications – Vendor/Agency

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o Comply with all laws, rules and regulations of the New Mexico State Corporation Commission

for Telecommunications and Security Systems; and

o Comply with all laws, rules and regulations from the Federal Communications Commission for

telecommunications.

Employment Supports

• Definition of Service:

o Employment support services provide support to the member in achieving and maintaining

employment in jobs of his/her choice in his/her community. The member must exhaust all

available vocational rehabilitation supports prior to requesting Employment Supports on his/her

SDCB care plan Employment Supports cannot duplicate any other SDCB service. Employment

Supports include two types of services: job coaching and job-development. The specific

employment support service to be provided must be clearly described in the member’s care

plan and must address specific employment-related activities;

o Employment Supports will be provided by staff at current or potential work sites. If member is

self-employed, Employment Supports may be provided in a setting other than a formal work

site. When employment support services are provided at a work site where persons without

disabilities are employed, payment is made only for the adaptations, supervision and training

required by members receiving SDCB services as a result of their disabilities, but does not

include payment for the supervisory activities rendered as a normal part of the business setting.

Employment Supports settings must be integrated in, and support full access for individuals

receiving Medicaid HCBS to the greater community, including opportunities to seek

employment, and work in competitive integrated settings, engage in community life, control

personal resources, and receive services in the community, to the same degree of access as

individuals not receiving Centennial Care CBs; and

o Providers will maintain a confidential case file for each individual that documents activities,

progress and scope of work outlined in the member’s SDCB care plan. Documentation is

maintained in the file of each member receiving this service to demonstrate that the service is

not available under a program funded under section 110 of the Rehabilitation Act of 1973 or

Individuals with Disabilities Education Act (IDEA).

• Employment Supports include the following services:

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o Job coaching is a service provided to members when the services are not otherwise available for

the member under a program funded under the Rehabilitation Act of 1973, the Division of

Vocational Rehabilitation (DVR) or through the New Mexico Department of Education. Job

coaching services are available 365 days a year, 24 hours a day. Services are driven by the

member’s SDCB care plan, budget and job. Medicaid funds are not used to pay the member. Job

coaches will adhere to the specific supports and expectations negotiated with the member and

employer prior to service delivery; and

o Job development services are provided to members when the services are not otherwise

available for the member under a program funded under the Rehabilitation Act of 1973, the

DVR or through the New Mexico Department of Education. Job development is a service

provided to members by skilled staff. The service has five components: job identification and

development activities; employer negotiations; job restructuring; job sampling; and job

placement.

• Scope of job coach services:

Job coach services will include, but are not limited to the following:

o Provide support to members as contained in the SDCB care plan as to achieve his/her outcomes;

o Teach vocational skills in a workplace setting;

o Employ job-coaching techniques and help members learn to accomplish job tasks to the

employer’s specifications;

o Increase the member’s capacity to engage in meaningful and productive interpersonal

interactions with co-workers, supervisors and customers;

o Identify and strengthen natural supports that are available to the member at the job site and

decrease paid supports in response to increased natural supports;

o Identify specific information about the member’s employment interests, preferences and

abilities;

o Effectively communicate with the employer about how to support the member to succeed

including any special precautions and considerations of the member’s disability, medications, or

other special concerns;

o Monitor and evaluate the effectiveness of the service and provide reports or documentation to

the member as requested in the SDCB care plan;

o Address behavioral, medical or other significant needs identified in the SDCB care plan;

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o Follow any individual specific therapeutic recommendations including speech, occupational

and/or PT, behavioral support, special diets and other therapeutic routines that are noted in the

SDCB care plan;

o Communicate effectively with the member including communication through the use of

adaptive equipment as well as the member’s communication dictionary, if applicable, at the

work site;

o Monitor the health and safety of the member;

o Model behavior, instruct and monitor any workplace requirements to the member;

o Adhere to professionally acceptable business attire and appearance, and communicate

professionally and in a respectful manner; and

o Adherence to rules of the specific workplace, including dress, confidentiality, safety rules and

other areas required by the employer.

• Scope of job development services:

o Identify potential employers and jobs in the area that provide work opportunities consistent

with the member’s preferences, interests and choice;

o Negotiate job functions, hours and supervision in the member’s best interest;

o Conduct satisfaction surveys as requested by the member;

o Broker relationships between the employer and the member in order to develop and maintain

job success;

o Identify potential employers and jobs in the area that provide work opportunities consistent

with the member’s preferences, interests and choices;

o Conduct job task analysis to ensure appropriate job match(es);

o Assess barriers to member skill development on the job and provide or obtain appropriate

accommodations tailored to the SDCB member’s ability to master task;

o Interact professionally in individual and group contacts, on the phone, in writing with various

levels of the company, including human resources and management;

o Assist the employer with ADA issues, Work Opportunity Tax Credit eligibility, requests for

reasonable accommodations, disability awareness training and workplace modification or make

referrals to appropriate agencies;

o Utilize, refer, and communicate with the DVR concerning job placement and referral activities

consistent with industry and SDCB standards;

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o Utilize DWS Navigators and One-Stop Career Centers, Business Leadership Network (BLN),

Chamber of Commerce, Job Accommodation Network (JAN), Small Business Development

Centers, Retired Executive, Businesses, community agencies, and the New Mexico Employment

Institute to achieve employment outcomes;

o Maintain on-going communication with various levels of the employer company to assure

satisfaction to both the member and the company;

o During the time of service delivery, ensure the member’s earnings and benefits are in

accordance with Fair Labor Standards Act. Each member’s earnings and benefits will be

reviewed at least semi-annually during the SDCB care plan year to ensure the appropriateness of

pay rates and benefits;

o Conduct a vocational assessment or profile as deemed necessary upon request of the member;

o Provide a career development plan as deemed necessary or upon the request of the member;

o Develop specific supports and expectations at the work site that are appropriate to the setting

and negotiated with the employer prior to and during employment;

o Verify and ensure that members receive job benefits and services such as paid time off, health

insurance, retirement, awards, raises, performance reviews and training consistent with those in

a similar job category; and

o Provide career and skill development for advancement and integration in work-related activities

or events.

• Job Coach Qualifications – Individual Provider:

o Be at least 18 years of age;

o Be qualified to perform the service and demonstrate capacity to perform required tasks;

o Be able to communicate successfully with the member;

o Experience as a job coach for at least one year;

o Experience for at least one year using job and task analyses;

o Trained on ADA;

o Trained on the purpose, function and general practices of the DVR;

o Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section 29-17-2

et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978, Section 27-7a-1

et seq. and 8.11.6 NMAC;

o Complete training on critical incident, abuse, neglect, and exploitation reporting;

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o Complete member specific training; the evaluation of training needs is determined by the

member or his/her legal representative; member is also responsible for providing and arranging

for provider training and supervising provider performance; training expenses for paid providers

cannot be paid for with the member’s annual budget; and

o Meet any other service qualifications, as specified in the SDCB rules.

• Job Developer Qualifications – Individual Provider:

o Be at least 18 years of age;

o Pass CBC and abuse registry screen;

o Experience as a job developer for at least one year;

o Experience for at least one year developing and using job task and analyses;

o Experience for at least one year working with the DVR, an independent living center or

organization that provides Employment Supports or services for people with disabilities;

o Trained on the purposes, functions and general practices entities such as:

▪ DWS Navigators;

▪ One-Stop Career Centers;

▪ BLN;

▪ Chamber of Commerce;

▪ JAN;

▪ Small Business Development Centers;

▪ Retired Executives; and

▪ New Mexico Employment Institute.

o Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section 29-17-2

et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978, Section 27-7a-1

et seq. and 8.11.6 NMAC;

o Complete training on critical incident, abuse, neglect, and exploitation reporting;

o Complete member specific training; the evaluation of training needs is determined by the

member or his/her legal representative; member is also responsible for providing and arranging

for provider training and supervising provider performance; training expenses for paid providers

cannot be paid for with the SDCB member’s annual budget; and

o Meet any other service qualifications, as specified in the SDCB rules.

• Job Coach and/or Job Developer Qualifications – Provider Agency:

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o Possess a current business license, if applicable;

o Meet financial solvency;

o Adhere to training requirements;

o Maintain individual records for each member within HIPAA compliance. The agency will

maintain a confidential case file for each member that documents activities, progress and scope

of work outlined in the member’s SDCB care plan;

o Develop and adhere to a records management policy;

o Develop and adhere to QA rules and requirements;

o Ensure job coaches have the following qualifications:

▪ Be at least 18 years of age;

▪ Be qualified to perform the service and demonstrate capacity to perform required tasks;

▪ Be able to communicate successfully with the member;

▪ Experience as a job coach for at least one year;

▪ Experience for at least one year using job and task analyses;

▪ Trained on ADA;

▪ Trained on the purpose, function and general practices of the DVR;

▪ Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section

29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978,

Section 27-7a-1 et seq. and 8.11.6 NMAC;

▪ Complete training on critical incident, abuse, neglect, and exploitation reporting;

▪ Complete member specific training; the evaluation of training needs is determined by the

member or his/her legal representative; member is also responsible for providing and

arranging for provider training and supervising provider performance; training expenses for

paid providers cannot be paid for with the member’s annual budget; and

▪ Meet any other service qualifications, as specified in the SDCB rules.

• Ensure job developers have the following qualifications:

o Be at least 18 years of age;

o Experience as a job developer for at least one year;

o Experience for at least one year developing and using job task and analyses;

o Experience for at least one year working with the DVR, an independent living center or

organization that provides Employment Supports or services for people with disabilities; and

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o Trained on the purposes, functions and general practices entities such as:

▪ DWS Navigators;

▪ One-Stop Career Centers;

▪ BLN;

▪ Chamber of Commerce;

▪ JAN;

▪ Small Business Development Centers;

▪ Retired Executives;

▪ New Mexico employment institute;

▪ Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section

29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978,

Section 27-7;

▪ a-1 et seq. and 8.11.6 NMAC;

▪ Complete training on critical incident, abuse, neglect, and exploitation reporting;

▪ Complete SDCB member specific training; the evaluation of training needs is determined by

the SDCB member or his/her legal representative; SDCB member is also responsible for

providing and arranging for provider training and supervising provider performance; training

expenses for paid SDCB providers cannot be paid for with the SDCB member’s annual

budget; and

▪ Meet any other service qualifications, as specified in the SDCB rules.

Environmental modification

• Definition of Service:

Environmental modification services include the purchase and/or installation of equipment and/or

making physical adaptations to a SDCB member's residence that are necessary to ensure the health,

welfare, and safety of the SDCB member or enhance the SDCB member’s level of independence. All

approved services shall be provided in accordance with applicable Federal, State, and local building

codes.

The environmental modification provider must ensure proper design criteria is addressed in the

planning and design of the adaptation, provide or secure licensed contractor(s) or approved

vendor(s) to provide construction services, provide administrative and technical oversight of

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construction projects, provide consultation to family members, providers and contractors

concerning environmental modification projects to the SDCB member's residence, and inspect the

final environmental modification project to ensure that the adaptations meet the approved plan

submitted to the SDCB member’s Care Coordinator for environmental adaptation.

Environmental modifications are managed by professional staff available to provide technical

assistance and oversight to environmental modification projects. All services shall be provided in

accordance with applicable Federal, State, and local building codes.

• Scope of Services:

o Environmental adaptations include the following:

▪ Installation of ramps and grab-bars;

▪ Widening of doorways/hallways;

▪ Installation of specialized electric and plumbing systems to accommodate medical

equipment and supplies;

▪ Installation of lifts/elevators;

▪ Modification of bathroom facilities (roll-in showers, sink, bathtub, and toilet modifications,

water faucet controls, floor urinals, and bidet adaptations and plumbing);

▪ Turnaround space adaptations;

▪ Installation of specialized accessibility/safety adaptations/additions;

▪ Installation of Trapeze and mobility tracks for home ceilings;

▪ Installation of Automatic door openers/doorbells;

▪ Installation of Voice-activated, light-activated, motion- activated and electronic devices;

▪ Installation of Fire safety adaptations;

▪ Installation of Air filtering devices;

▪ Installation of heating/cooling adaptations;

▪ Installation of glass substitute for windows and doors;

▪ Installation of modified switches, outlets or environmental controls for home devices; and

▪ Installation of alarm and alert systems, emergency response systems, and/or signaling

devices.

o Environmental modification Qualifications – Individual Contractor and Agency Contractor:

▪ Current business license;

▪ Appropriate plumbing, electrician, contractor license; and/or

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▪ Appropriate technical certification or other license to perform the modification.

o The environmental modification provider must:

▪ Provide a one-year warranty from the completion date on all parts and labor;

▪ Have a working knowledge of environmental modifications and be familiar with the needs of

persons with functional limitations in relation to environmental modifications;

▪ Provide consultation to family members, providers and MCOs concerning environmental

modification projects to the SDCB member’s individual’s residence, and inspect the final

environmental modification project prior to the member/EOR requesting the final payment

to ensure that the adaptations meet the approved plan as submitted and approved for

environmental adaptation; and

▪ Provider must establish and maintain financial reporting and accounting for each member.

o The environmental modification provider will submit the environmental modification Service

Cost Quote Packet containing the following information and documentation to the MCO:

▪ Environmental modification evaluation;

▪ Service Cost Estimate;

▪ Photographs of the proposed modifications;

▪ The estimated start date of the work on the proposed modification; (equipment, materials,

supplies, labor, travel, per diem, report writing time, and completion date of modification);

▪ Letter of Acceptance of Service Cost Estimate signed by the SDCB member/EOR;

▪ Letter of Permission from property owner. If the property owner is someone other than the

member, the letter must be signed by the property owner and the member;

▪ The Construction Letter of Understanding. If the property owner is someone other than the

member, the letter must be signed by the property owner and the member; and

▪ Documentation demonstrating compliance with the ADA.

o The environmental modification provider must submit the following to the MCO, after the

completion of work:

▪ Letter of Approval of Work completed signed by the SDCB member/EOR; and

▪ Photographs of the completed modifications.

o The MCO must submit a Care Coordinator Individual Assessment of Need to the provider.

o Reimbursement:

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Environmental modification providers must maintain appropriate record keeping of services

provided, and fiscal accountability as indicated in the Medicaid PPA. Billing is on a project basis,

one unit per environmental modification project. Reimbursement for environmental

modification services will be based on the negotiated rate with the SDCB member/EOR;

Environmental modification services are limited to $5,000.00 every five years, beginning from

the first date of service. Additional services may be requested if the member’s health and safety

needs exceed the specified limit. The $5,000.00, five-year time limit applies across all CB

packages where environmental modifications are a covered service. Example: an ABCB member

receives an environmental modification of $2,300.00 leaving a $2,700.00 available balance for

future environmental modification. Six months later the ABCB member transitions to the SDCB,

the member now has $2,700.00 available for environmental modifications; and

Environmental modifications exclude those adaptations or improvements to the home that are

of general utility and are not of direct medical or remedial benefit to the member, such as

carpeting, fences, roof repair, storage sheds or other outbuildings, furnace replacement,

insulation, and other general household repairs. Adaptations that add to the total square

footage of the home are also excluded from this benefit except when necessary to complete an

adaptation related to the member’s medical condition.

Home Health Aide

• Definition of Service:

HH Aide services provide total care or assist a member in all activities of daily living. HH Aide

services assist the member in a manner that will promote and improve the member’s quality of life

and provide a safe environment for the member. HH aide services can be provided outside the

member’s home;

State plan HH Aide services are intermittent and are provided primarily on a short-term basis;

whereas, in SDCB, HH Aide services are hourly services for members who need this service on a

long-term basis; and

HH Aides may provide basic non-invasive nursing assistant skills within the scope of their practice.

HH Aides do not administer medication(s), adjust oxygen levels, perform any intravenous

procedures or perform sterile procedures. HH Aide services are not duplicative of self-directed PCS.

• Scope of Services:

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o Provide personal hygiene (e.g. sponge bathing, showering, bed shampooing, shaving, oral

hygiene dressing);

o While under the supervision of a licensed physical therapist or licensed nurse (RN or LPN), assist

with ambulation, transfer and range of motion exercises;

o Assist with menu planning, meal/snack preparation and assist member with eating as necessary;

o As ordered by a physician and under supervision of a licensed nurse (RN or LPN), he/she will

assist with bowel and bladder elimination with activities such as: catheter care, colostomy care,

enemas, insertion of non-prescribed suppository, prosthesis care and vital signs;

o Provide homemaking services (e.g. laundry, linen change, cleaning);

o Pick up medication(s);

o Assist or prompt member in self-administration of medication(s);

o Observe general condition of member and report changes to supervisor;

o Document SDCB member’s status and services furnished, infection control procedures; and

o Recognize emergencies and adhere to emergency procedures.

• HH Aide Qualifications – Agency Provider:

o Licensed in New Mexico as an HH agency, RHC or FQHC;

o Possess current business license;

o Meet financial solvency;

o Adhere to training requirements;

o Maintain individual records for each SDCB member within HIPAA compliance;

o Develop and adhere to records management policy;

o Develop and adhere to QA policies and processes;

o Supervision must be performed by an RN. Such supervision must occur at least once every 60

calendar days in the member's home and shall be in accordance with the New Mexico Nurse

Practice Act and be specific to the member's SDCB care plan. Contact must be made with family

members during supervision; and

o Ensure all assigned staff meets the following qualifications:

▪ Be at least 18 years of age;

▪ Be qualified to perform the service and demonstrate capacity to perform required tasks;

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▪ Have successfully completed a HH aide training program, as described in 42 CFR 484.36(a)(1)

and (2); or have successfully completed a HH aide training program pursuant to 7.28.2.30

NMAC. Copies of CNA certificates must be maintained in the personnel file of the HH aide;

▪ Be able to communicate successfully with the member;

▪ Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section

29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978,

Section 27-7a-1 et seq. and 8.11.6 NMAC;

▪ Complete training on critical incident, abuse, neglect, and exploitation reporting; and

▪ Meet any other service qualifications, as specified in the SDCB rules.

Nutritional Counseling

• Definition of Service:

o Nutritional Counseling services are designed to meet the unique food and nutritional needs of

SDCB members. This does not include oral-motor skill development services, such as those

provided by a speech pathologist.

• Scope of Services:

o Assessment of nutritional needs;

o Development and/or revision of the SDCB member’s nutritional plan; and

o Counseling and nutritional intervention and observation and technical assistance related to

implementation of the nutritional plan.

• Nutritional Counseling Qualifications - Individual Provider:

o Be licensed per the New Mexico Regulation and Licensing Department; Nutrition and Dietetics

Practice Act, NMSA 1978, Section 61-7A et. seq.

• Nutritional Counseling Qualifications - Agency Provider:

o Current business license; and provide a tax identification number;

o Rendering providers are Licensed per the New Mexico Regulation and Licensing Department;

Nutrition and Dietetics Practice Act, NMSA 1978, Section 61-7A et. seq.

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Private Duty Nursing for Adults

• Definition of Service:

o Private duty nursing for adult services includes activities, procedures, and treatment for a

member’s physical condition, physical illness or chronic disability. Children (individuals under

the age of 21) receive this service through the State plan EPSDT.

• Scope of Services:

o Private duty nursing services for adults may include performance, assistance and education with

the following tasks:

▪ Medication management, administration and teaching;

▪ Aspiration precautions;

▪ Feeding tube management, gastrostomy and jejunostomy;

▪ Skin care;

▪ Weight management;

▪ Urinary catheter management;

▪ Bowel and bladder care; wound care; health education and screening;

▪ Infection control;

▪ Environmental management for safety;

▪ Nutrition management;

▪ Oxygen management;

▪ Seizure management and precautions;

▪ Anxiety reduction;

▪ Staff supervision; and

▪ Behavior and self-care assistance.

o Private Duty Nursing Qualifications – Agency:

▪ Licensed in New Mexico as a HH Agency, RHC or FQHC agency;

▪ Possess current business license;

▪ Meet financial solvency;

▪ Adhere to training requirements;

▪ Maintain individual records for each member within HIPAA compliance;

▪ Develop and adhere to a records management policy;

▪ Develop and adhere to QA policies and processes;

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▪ Ensure all assigned staff meet the following qualifications;

▪ Licensed by the New Mexico State Board of Nursing as a RN or LPN;

▪ Demonstrate capacity to perform required tasks;

▪ Be able to communicate successfully with the member;

▪ Complete training on critical incident, abuse, neglect, and exploitation reporting;

▪ Individual RN/LPN providers must be licensed by the New Mexico State board of nursing as

an RN or LPN; and

▪ Meet any other service qualifications, as specified in the SDCB rules.

o Private Duty Nursing Qualifications – Individual:

▪ Provide a tax identification number;

▪ Individual RN/LPN providers must be licensed by the New Mexico State Board of Nursing as

an RN or LPN;

▪ Demonstrate capacity to perform required tasks;

▪ Be able to communicate successfully with the SDCB member;

▪ Complete training on critical incident, abuse, neglect, and exploitation reporting; and

▪ Meet any other service qualifications, as specified in the SDCB rules.

Related Goods

• Definition of Service:

Related Goods are services, goods, and equipment, including supplies, fees or memberships (such as

for conferences or classes), which support the SDCB member to remain in the community, decrease

the need for other Medicaid services and reduce the risk for institutionalization. Related goods must

promote personal safety and health, accommodate the SDCB member in managing his/her

household and/or facilitate ADLs. The related goods must not be available through another source

including the Medicaid State Plan and/or Medicare, and the SDCB member must not have the

personal funds needed to purchase the goods; and

Related goods must be documented in the SDCB care plan in a manner that clearly describes how

the related good will advance the desired outcomes in the SDCB member’s care plan. Related goods

must be linked to the SDCB member’s identified needs and are intended for the sole use of the SDCB

member, and one caregiver, if appropriate. All related goods must be approved by the MCO/UR. The

cost and type of related good is subject to approval by the MCO/UR. SDCB members are not

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guaranteed the exact type and model of related good that is requested. The Support Broker and/or

the Care Coordinator can work with the SDCB member to find other (including less costly)

alternatives. Items that are purchased with SDCB funds cannot be returned for store credit, cash or

gift cards. Experimental or prohibited treatments and related goods are excluded. For members who

enter the SDCB program after January 1, 2019, related goods are limited to a total maximum of

$2,000.00 annually.

• Scope of Services:

Related goods must address a specific, assessed need identified in the member’s CNA (including

improving and maintaining the member’s opportunities for full membership in the community) and

must directly relate to the member’s qualifying condition or disability. Related goods must explicitly

address the member’s clinical, functional, medical or habilitative needs;

Related goods must meet all of the following requirements:

o Are related to a need or goal identified in the approved care plan;

o Are for the purpose of increasing independence or substituting for human assistance, to the

extent the expenditures would otherwise be made for that human assistance;

o Promote opportunities for community living and inclusion;

o Are able to be accommodated within the member’s budget without compromising the

member’s health or safety; and

o Are provided to, or directed exclusively toward, the benefit of the member.

Medicaid does not pay for the purchase of related goods or services that a household not including

a person with a disability would be expected to pay for as a routine household or personal expense.

Examples include, but are not limited to:

o Goods or services that are considered primarily recreational or diversional;

o Cell phones and cell phone service for members who are minors (these are items that LRI such

as a parent/guardian, or spouse would ordinarily purchase for household members of the same

age who do not have a disability or chronic illness);

o Cell phone services including fees for data and GPS in excess of $100.00 per month or more than

one cell phone per SDCB member;

o Cell phone services that include more than one cell phone or cell phone line per member; cell

phone service, including data, is limited to the cost of $100.00 per month;

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o Room and board, meaning shelter expenses (including property-related costs such as home and

property maintenance, insurance policies, utilities and all deposits; and all food items other than

nutritional supplements as approved in the SDCB care plan);

o Purchase of usual and customary furniture/home furnishings,

o Regularly scheduled upkeep, maintenance and repairs of a home, addition of fences, insulation,

construction of storage sheds or other outbuildings, except upkeep and maintenance of

modifications or alterations to a home which are an accommodation directly related to the

member’s qualifying condition or disability;

o Regularly scheduled upkeep, maintenance and repairs of a vehicle or van, or tire purchase or

replacement, except upkeep and maintenance of modifications or alterations to a vehicle or

van, which is an accommodation directly related to the member’s qualifying condition or

disability.

o Purchase, lease, or rental of a vehicle, including recreational vehicles;

o Memberships/fees related to religious activities/events;

o Purchase of animals and the costs of maintaining animals, including the purchase of food,

veterinary visits, grooming and boarding but with the exception of training and certification for

service dogs;

o Purchase of insurance policies, such as automobile, health, life, burial, renter’s, home-owner,

service warrantees or other such policies, including the purchase of cell phone insurance;

o Personal goods or items not related to the member’s qualifying condition or disability, including

clothing and personal hygiene products and accessories;

o Moving expenses including but not limited to the cost of moving truck rental, gas/mileage,

labor, storage, moving equipment and supplies;

o Vacation expenses, including means of transport, guided tours, meals, tips, lodging or similar

recreational expenses including fuel, mileage or driver time reimbursement for vacation travel

by an automobile;

o Costs associated with conferences or classes, including airfare, lodging, mileage/gas, or meals;

o Training expenses for employees;

o Professional housecleaning or yard maintenance;

o Formal academic degrees or certification-seeking education, educational services covered by

IDEA, or vocational training provided by the public education department, DVR; and

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o For electronics such as cell phones, computers (including desktop, laptop, and tablets),

monitors, printers and fax machines, copiers, and other electronic equipment, no more than

one of each type of item may be purchased at one time, and member electronics may not be

replaced more frequently than once every three years.

• Related Goods Qualifications - Vendor Agency Provider:

o Valid tax identification for the state and Federal governments.

Respite

• Definition of Service:

o Respite is to be used to give the primary caregiver a break on an episodic basis in the event of an

emergency or to prevent burnout. Respite provides a temporary relief to the primary caregiver

of a SDCB member during times when the caregiver would normally provide unpaid care.

Respite services can be provided in the SDCB member’s home, the provider’s home, in

community setting of the family’s choice (e.g., community center, swimming pool and park, or

at a center in which other individuals are provided care); and

o Respite services may be provided by eligible individual respite providers; RN or LPN; or respite

provider agencies.

• Scope of Services:

Respite services include, but are not limited to the following:

o For members meeting NF LOC, respite services are limited to a maximum of 300 hours annually

per care plan year provided there is a primary caregiver. The 300-hour respite service applies

across all CB packages where respite is a covered service. Additional hours may be requested if

an eligible beneficiary’s health and safety needs exceed the specified limit;

o Assist with routine ADLs;

o Enhance self-help skills, leisure time skills and community and social awareness;

o Provide opportunities for leisure, play and other recreational activities;

o Provide opportunities for community and neighborhood integration and involvement;

o Provide opportunities for the SDCB member to make his/her own choices with regards to daily

activities;

o Respite services do not include the cost of room and board;

o Cannot be used for purposes of day-care;

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o Cannot be provided to school age children during school hours; and

o Respite must be documented through the EVV system.

• Respite Qualifications – Individual Provider:

o Be at least 18 years of age;

o Be qualified to perform the service and demonstrate capacity to perform required tasks;

o Be able to communicate successfully with the SDCB member;

o Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section 29-17-2

et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978, Section 27-7a-1

et seq. and 8.11.6 NMAC;

o Complete training on critical incident, abuse, neglect, and exploitation reporting;

o Complete member specific training; the evaluation of training needs is determined by the

member or his/her legal representative; member is also responsible for providing and arranging

for provider training and supervising provider performance; training expenses for paid providers

cannot be paid for with the SDCB member’s annual budget;

o Meet any other service qualifications, as specified in the SDCB rules and the Manual; and

o Individual RN/LPN providers must be licensed by the New Mexico State Board of Nursing as an

RN or LPN.

• Respite Qualifications - Provider Agency:

o Possess a current business license, if applicable;

o Meet financial solvency;

o Adhere to training requirements;

o Maintain individual records for each SDCB member within HIPAA compliance;

o Develop and adhere to a records management policy;

o Develop and adhere to QA rules and requirements; and

o Ensure all assigned staff meet the following qualifications:

▪ Be at least 18 years of age;

▪ Be qualified to perform the service and demonstrate capacity to perform required tasks;

▪ Be able to communicate successfully with the SDCB member;

▪ Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section

29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978,

Section 27-7a-1 et seq. and 8.11.6 NMAC;

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▪ Complete training on critical incident, abuse, neglect, and exploitation reporting;

▪ Complete SDCB member specific training; the evaluation of training needs is determined by

the SDCB member or his/her legal representative; member is also responsible for providing

and arranging for provider training and supervising provider performance; training expenses

for paid providers cannot be paid for with the SDCB member’s SDCB annual budget;

▪ Individual RN/LPN providers must be licensed by the New Mexico State Board of Nursing as

an RN or LPN; and

▪ Meet any other service qualifications, as specified in the SDCB rules and the Manual.

Self-Directed Personal Care

• Definition of Service:

Self-directed PCS are provided on a continuing basis to assist the member with accomplishing tasks

he/she would normally do for him/herself if he/she did not have a disability. Self-directed PCS are

provided in the member’s home and in the community, depending on the member’s needs. The

member/EOR identifies the self-directed personal care worker’s training needs. If the SDCB

member/EOR is unable to do the training him/herself, the SDCB member/EOR arranges for the

needed training;

Services are not intended to replace supports available from a primary caregiver or natural supports.

Although a member’s assessment for the amount and types of services may vary, Self-directed PCS

are not provided 24 hours a day. Allocation of time and services must be directly related to an

individual’s functional level to perform ADLs and IADLs as indicated in the CNA; and this service is

not available for members under age 21 because PCS are covered under the Medicaid State Plan as

expanded EPSDT benefits for members under age 21.

• Scope of Services:

o Self-directed PCS include but are not limited to the following:

▪ Assist the member with ADLs;

▪ Perform general household tasks, not including services such as yard maintenance;

▪ Provide companionship to acquire, maintain or improve social interaction skills in the

community; and

▪ Attend trainings as designated by the member in the care plan.

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o Self-Directed Personal Care Qualifications – Individual Provider:

▪ Be at least 18 years of age;

▪ Be qualified to perform the service and demonstrate capacity to perform required tasks;

▪ Be able to communicate successfully with the member;

▪ Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section

29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978,

Section 27-7a-1 et seq. and 8.11.6 NMAC and the National Sex Offender Registry;

▪ Complete training on critical incident, abuse, neglect, and exploitation reporting;

▪ Complete member specific training; the evaluation of training needs is determined by the

member or his/her legal representative; member is also responsible for providing and

arranging for provider training and supervising provider performance; training expenses for

paid providers cannot be paid for with the member’s annual budget;

▪ Use the State-approved EVV system to record location of services and time worked; and

▪ Meet any other service qualifications, as specified in the SDCB rules.

o Self-Directed Personal Care Qualifications – Agency Provider:

▪ HHAs must hold an HHA license;

▪ Possess a current business license, if applicable;

▪ Meet financial solvency;

▪ Adhere to training requirements;

▪ Maintain individual records for each SDCB member within HIPAA compliance;

▪ Develop and adhere to a records management policy;

▪ Develop and adhere to QA rules and requirements; and

▪ Ensure all assigned staff meet the following qualifications:

• Be at least 18 years of age;

• Be qualified to perform the service and demonstrate capacity to perform required tasks;

• Be able to communicate successfully with the member;

• Pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section

29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screening pursuant to NMSA

1978, Section 27-7a-1 et seq. and 8.11.6 NMAC and the National Sex Offender Registry;

• Complete training on critical incident, abuse, neglect, and exploitation reporting;

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• Complete member specific training; the evaluation of training needs is determined by

the member or his/her legal representative; member is also responsible for providing

and arranging for employee training and supervising employee performance; training

expenses for paid employees cannot be paid for with the member’s annual budget;

▪ Ensure employees use the State-approved EVV system to record location of services and

time worked; and

• Meet any other service qualifications, as specified in the SDCB rules and the Manual.

Skilled Maintenance Therapies Services

• Definition of Service:

Skilled maintenance therapies are provided when Medicaid State Plan skilled therapy services are

exhausted. Adult members in SDCB access therapy services under the Medicaid State Plan for acute

and temporary conditions that are expected to improve significantly in a reasonable and generally

predictable period of time. A signed therapy referral for treatment must be obtained from the

member’s PCP. The referral will include frequency, estimated duration of therapy, and

treatment/procedures to be rendered. Therapy services provided to adults in SDCB are to focus on

health maintenance, improving functional independence, community integration, socialization,

exercise or to enhance supports and normalization of family relationships.

o PT is the diagnosis and management of movement dysfunction and the enhancement of physical

and functional abilities;

o OT is the diagnosis, assessment and management of functional limitations intended to assist

adults to regain, maintain, develop and build skills that are important for independence,

functioning and health; and

o SLT services preserve speech fluency, voice, verbal, written language, auditory comprehension,

cognition, swallowing dysfunction, oral pharyngeal or laryngeal and sensor motor competencies.

Speech language pathology is also used when a SDCB member requires the use of an

augmentative communication device. Based upon therapy goals, services may be delivered in an

integrated natural setting, clinical setting or in a group.

• Scope of Services

o PT:

• Diagnostic activities to determine the dysfunction of physical and functional activities;

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• Activities to increase, maintain or reduce the loss of functional skills;

• Treat specific condition(s) clinically related to a member’s qualifying condition or

disability;

• Activities to support the member’s health and safety needs; and

• Identify, implement and train on therapeutic strategies to support the member, family

and/or staff in the home setting or other environments as addressed in the SDCB care

plan.

o OT:

• Diagnostic activities to determine skills assessment and treatment;

• Write treatment program to improve one’s ability to perform daily tasks;

• Comprehensive home, employment and/or volunteer sites evaluations with adaptation

recommendations;

• Provide guidance to family members and caregivers;

• Make assistive technology recommendations and provide usage training for members,

family and staff; and

• Identify, implement and train on therapeutic strategies to support the SDCB member,

family and/or staff in the home setting or other environments as addressed in the SDCB

care plan.

o Speech and Language Pathology:

• Improve or maintain the member’s capacity for successful communication or to lessen

the effects of the member’s loss of communication skills;

• Consultation on usage and training on augmentative communication devices;

• Activities to improve or maintain the member’s ability to eat food, drink liquid and

manage oral secretions with minimal risk of aspiration or other injuries or illness related

to swallowing disorders; and

• Activities to identify, implement, and train on therapeutic strategies to support the

member, his/her family and/or staff consistent with the member’s Care Plan.

o Therapy Qualifications – Individual Therapist Provider:

• Provide a tax identification number; and

• Maintain a case file within HIPAA guidelines for the member to include:

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o Member’s SDCB care plan;

o Reports as requested in the care plan;

o Contact notes;

o Training roster(s); and

o Assessments for environmental modification requests.

▪ Licensures:

• Physical therapists will be licensed as per the New Mexico Regulation and Licensing

Department; Physical Therapy Act NMSA 1978, Section 61-12-1.1 et. seq;

• Occupational therapists will be licensed as per the New Mexico Regulation and Licensing

Department; Occupational Therapy Act NMSA 1978, Section 61-12A- 1et.seq.; and

• Speech and Language Pathologists will be licensed as per the New Mexico Regulation

and Licensing Department; Occupational Therapy Act NMSA 1978, Section

61-14B- 1et.seq.

o Therapy Qualifications – Provider Agency:

• Current business license;

• Provide tax identification number;

• Ensure physical therapists maintain a case file within HIPAA guidelines for the member

to include:

o Member’s SDCB care plan;

o Reports as requested in the SDCB care plan;

o Contact notes;

o Training roster(s); and

o Environmental modification requests.

• Ensure therapists has appropriate license for service:

o Physical therapists will be licensed as per the New Mexico Regulation and Licensing

Department; Physical Therapy Act NMSA 1978, Section 61-12-1.1 et. seq.;

o Occupational therapists will be licensed as per the New Mexico Regulation;

o Licensing Department; Occupational Therapy Act NMSA 1978, Section

61-12A- 1et.seq.; and

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o Speech and Language Pathologists will be licensed as per the New Mexico

Regulation and Licensing Department; Occupational Therapy Act NMSA 1978,

Section 61-14B- 1et.seq.

Specialized Therapies Services

• Definition of Service:

Specialized therapies are non-experimental therapies or techniques that have been proven effective

for certain conditions. Services must be related to the member’s disability or condition and ensure

the member’s health and welfare in the community. The service will supplement to (not replace) the

member’s natural supports and other community services for which the member may be eligible.

Experimental or investigational procedures, technologies or therapies and those services covered in

Medicaid State Plans are excluded. For members who enter the SDCB program on or after January 1,

2019, specialized therapies are limited to a total maximum of $2,000.00 annually.

Only the specific specialized therapy services outlined below are covered through the SDCB.

• Scope of Services:

o Acupuncture is a distinct system of primary health care;

The goal of acupuncture is to prevent, cure or correct any disease, illness, injury, pain or other

physical or mental condition by controlling and regulating the flow and balance of energy, form

and function to restore and maintain PH and increased mental clarity. Acupuncture may provide

effective pain control, decreased symptoms of stress, improved circulation and a stronger

immune system, as well as other benefits. See Acupuncture and Oriental Medicine Practitioners

16.2.1 NMAC.

o Biofeedback uses visual, auditory or other monitors to provide SDCB members physiological

information of which they are normally unaware. This technique enables a member to learn

how to change physiological, psychological and behavioral responses for the purposes of

improving emotional, behavioral and cognitive health performance. Biofeedback may assist in

strengthening or gaining conscious control over the above processes in order to self-regulate.

Biofeedback is also useful for muscle re- education of specific muscle groups or for treating

pathological muscle abnormalities of spasticity, incapacitating muscle spasm or weakness;

o Chiropractic care is designed to locate and remove interference with the transmissions or

expression of nerve forces in the human body by the correction of misalignments or

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subluxations of the vertebral column and pelvis. Chiropractic care restores and maintains health

for treatment of human disease primarily by, but not limited to adjustment and manipulation of

the human structure. Chiropractic therapy may positively affect neurological function, improve

certain reflexes and sensations, and increase range of motion and lead to improved general

health. See Chiropractic Practitioners 16.4.1 NMAC;

o Cognitive rehabilitation therapy is designed to improve cognitive functioning with the following

activities: reinforcing, strengthening, or re-establishing previously learned patterns of behavior;

establishing new patterns of cognitive activity; or compensatory mechanisms of impaired

neurological systems. Treatments may be focused on improving a particular cognitive domain

such as attention, memory, language, or executive functions. Alternatively, treatments may be

skill-based, aimed at improving performance of activities of daily living. The overall goal is to

restore function in a cognitive domain or set of domains or to teach compensatory strategies to

overcome specific cognitive problems;

o Hippotherapy is a physical, occupational and SLT treatment strategy that utilizes equine

movement as part of an integrated intervention program to achieve functional outcomes.

Hippotherapy applies multidimensional movement of a horse for members with movement

dysfunction and may increase mobility and rage of motion, decrease contractures and aid in

normalizing muscle tone. Hippotherapy requires that the member use cognitive functioning

especially for sequencing and memory. Members with attention deficits and behavior problems

are redirecting attention and behaviors by focusing on the activity. Hippotherapy involves

therapeutic exercise, neuromuscular education, kinetic activities, therapeutic activities, sensory

integration activities and individual speech therapy. The activities may also help improve

respiratory function and assist with improved breathing and speech production. Hippotherapy

must be performed by a physical therapist, occupational therapist, or speech therapist licensed

by the New Mexico Regulation and Licensing Department;

o Massage therapy is the assessment and treatment of soft tissues and their dysfunction for

therapeutic purposes primarily for comfort and relief of pain. It includes gliding, kneading,

percussion, compression, vibration, friction, nerve strokes, stretching the tissue and exercising

range of motion and may include the use of oils, salt glows, hot or cold packs or hydrotherapy.

Massage increases the circulation, helps loosen contracted, shortened muscles and can

stimulate weak muscles to improve posture and movement, improves range of motion and

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reduces spasticity. Massage therapy may increase, or help sustain, a member’s ability to be

more independent in the performance of activities of daily living; thereby, decreasing

dependency upon others to perform or assist with basic daily activities. See Massage Therapists

16.7.1 NMAC;

o Naprapathy focuses on the evaluation and treatment of neuro-musculoskeletal conditions and is

a system for restoring functionality and reducing pain in muscles and joints. The therapy uses

manipulation and mobilization of the spine and joints and muscle treatments such as stretching

and massage. Based on the concept that constricted connective tissue (ligaments, muscles and

tendons) interfere with nerve, blood and lymph flow, Naprapathy uses manipulation of

connective tissue to open these channels of body function. See Naprapathic Practitioners 16.6.1

NMAC; and

o Native American healing therapies encompass a wide variety of culturally-appropriate therapies

that support members in their communities by addressing their physical, emotional and spiritual

health. Treatments may include prayer, dance, ceremony and song, plant medicines and foods,

participation in sweat lodges, and the use of meaningful symbols of healing, such as the

medicine wheel and/or other sacred objects.

• Specialized Therapy Qualifications – Individual Provider:

o Current New Mexico state license as applicable:

▪ Acupuncture and Oriental medicine license;

▪ Biofeedback – license in a healthcare profession whose scope of practice includes

biofeedback, and appropriate specialized training and clinical experience and supervision;

▪ Chiropractic Physician license;

▪ Cognitive rehabilitation therapy – license in a health care profession whose scope of

practice includes cognitive rehabilitation therapy, and appropriate specialized training and

clinical experience and supervision;

▪ Hippotherapy – licensed occupational therapist, physical therapist, or speech therapist;

▪ Massage therapy license; and

▪ Naprapathic physician license.

o Native American Healers – individuals who are recognized as healers within their communities.

This form of therapy may be provided by community-recognized medicine men and women and

others as healers, mentors and advisors to SDCB members.

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• Specialized Therapy Qualifications - Provider Agency:

o Current business license;

o Tax identification number; and

o Group practice/vendor staff must hold current New Mexico licensure and training in their

respective discipline as follows:

▪ Acupuncture and Oriental Medicine license;

▪ Biofeedback – license in a healthcare profession whose scope of practice includes

biofeedback, and appropriate specialized training and clinical experience and supervision;

▪ Chiropractic Physician license;

▪ Cognitive rehabilitation therapy – license in a health care profession whose scope of

practice includes cognitive rehabilitation therapy, and appropriate specialized training and

clinical experience and supervision;

▪ Hippotherapy – license in a health care profession whose scope of practice includes

Hippotherapy and appropriate specialized training and experience;

▪ Massage therapy license; and

▪ Naprapathic physician license.

Start-Up Goods

• Definition of Service:

Start-up goods are available to a member who is transitioning from the ABCB to the SDCB for the

first time. Start-up goods are limited to one time. Start-up goods help the member in self-directing

his or her services. Examples of start-up goods include, but are not limited to a computer, fax

machine, and printer. All start-up goods must be approved by the MCO. The cost and type of related

good is subject to approval by the MCO. Start-up goods must be purchased during the member’s

first budget period. Start-up goods are limited to $2,000.00.

Transportation (Non-Medical)

• Definition of Service:

Transportation services are offered in order to enable SDCB members to gain access to and from

community services, activities and resources, as specified by the SDCB care plan. Transportation

services are intended for access to the member’s local area, within a 75-mile radius of the SDCB

member’s home. Transportation services under SDCB are non-medical in nature, whereas

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transportation services provided under the Medicaid State Plan are to transport members to

medically necessary physical and BH services. Transportation for the purpose of picking up

pharmacy prescriptions is allowed. Transportation for the purpose of vacation is not covered

through the SDCB;

Non-medical transportation services for minors is not a covered service;

Non-medical transportation may be reimbursed:

o To the driver by the mile; and/or

o Through the purchase of a bus pass or local taxi.

Payments are made to the member’s individual transportation employee or vendor or to a public or

private transportation service vendor. Payments cannot be made to the SDCB member. Whenever

possible, natural supports should provide this service without charge. For members who enter the

SDCB program on or after January 1, 2019, SDCB non-medical transportation is limited to a total

maximum of $1,000.00 annually.

• Scope of Services:

The service will be provided as specified in the member’s SDCB care plan. SDCB non-medical

transportation services cannot be used instead of, or to replace, medical transportation services

available under the Medicaid State Plan; and

Payment is allowable for transportation to and from specific locations/sites that provide specific

services that are approved in the member’s care plan goals.

• Transportation Qualifications - Individual Provider:

o Be at least 18 years of age;

o Possess a valid New Mexico driver’s license;

o Be free of physical or mental impairment that would adversely affect driving performance;

o No driving while intoxicated convictions within the previous two years;

o No chargeable (at fault) accidents within the previous two years;

o Have current CPR/First Aid certification;

o Complete training on critical incident, abuse, neglect, and exploitation reporting; and

o Possess and maintain current insurance policy and registration.

• Transportation Qualifications – Provider Agency:

o Current business license;

o Valid tax identification number;

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o Have a current basic First Aid kit in the vehicle;

o Each vehicle will contain a current insurance policy and registration; and

o Ensure drivers meet individual qualifications:

▪ Be at least 18 years of age;

▪ Possess a valid New Mexico driver’s license;

▪ Be free of physical or mental impairment that would adversely affect driving performance

▪ No driving while intoxicated convictions within the previous two years;

▪ No chargeable (at fault) accidents within the previous two years;

▪ Have current CPR/First Aid certification;

▪ Complete training on critical incident, abuse, neglect, and exploitation reporting;

▪ Trained on New Mexico Department of Health Improvement (DHI) Critical Incident

Reporting and Procedures; and

▪ Possess current insurance policy and registration.

9.11. Self-Directed Non-Covered Services

When a member requests a non-covered service or good, the Support Broker and/or Care Coordinator

shall work with the member to find other (including less costly) alternatives. Services and goods that are

not covered by the SDCB program include, but are not limited to:

• The SDCB Program is the payer of last resort; and

• Any service or good, the provision of which would violate Federal or State statutes, rules or

guidance. This includes services that are recreational or diversional, which are not deemed eligible

SDCB services by CMS. Recreational and diversional in nature is defined as inherently and

characteristically related to activities done for enjoyment. This includes, but is not limited to tickets

for movies, theatrical and musical performances, sporting events, zoos or museums.

9.12. SDCB Budget and Care Plan Approval Process

The Care Coordinator adds the member to FOCoSonline when the member has expressed a desire to

transfer to SDCB by signing the SDCB statement. Once the member selects the Support Broker agency

he/she wishes to work with, the Care Coordinator informs the Support Broker agency of the selection.

After the Support Broker meets with the member and an anticipated transfer date is agreed upon, the

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Support Broker creates a Working Plan shell with the anticipated SDCB care plan dates. Once the

Working Plan shell is created, the Care Coordinator shall enter the SDCB budget amount in FOCoSonline.

9.13. Initial SDCB Budget Determination Process

The SDCB budget is determined by the Care Coordinator and is based on two factors: the needs

identified in the CNA, and the amount and type of services the member has been receiving in the ABCB.

Both of these evaluations are used to assign the SDCB budget amount for development of the SDCB care

plan. The Care Coordinator shall provide the Support Broker with the SDCB budget amount.

The member must receive his/her HCBS in the ABCB for a minimum of 120 calendar days before

transferring to the SDCB. The initial 12-month SDCB budget shall be pro-rated based on the number of

months already completed in the ABCB. The SDCB member may request a new CNA if the SDCB member

thinks his/her needs were not adequately addressed in the initial CNA.

9.14. Initial SDCB Care Plan Approval Process

Once the Care Plan is developed, the Support Broker, in cooperation with the member, shall inform the

Care Coordinator that the Care Plan is ready for review. Once the Care Coordinator reviews the Care

Plan, the Care Coordinator shall formally submit the care plan in FOCoSonline to the MCO for review and

approval/denial decisions. The member’s Care Plan must be reviewed, and each individual requested

goal approved or denied by the MCO and written notification must be sent to the member before any

services may be utilized and related goods may be purchased. If, during the process of reviewing the

Care Plan and all subsequent Care Plan revisions, the MCO is unable to make a decision on a goal, due to

insufficient information, the MCO shall initiate an RFI via FOCoSonline. The MCO shall provide written

notification to the member and the Support Broker, specifying what is needed by the MCO to satisfy the

RFI. It is the member’s responsibility to provide a timely and complete response to the RFI. The Support

Broker/Care Coordinator may assist the member in obtaining the requested documents to fulfill the RFI.

The member/Support Broker must provide the RFI response to the Care Coordinator within 15 calendar

days from the date of the RFI letter. After review of the RFI response the Care Coordinator shall submit

the RFI response to the MCO for approval/denial decision. If the requested information is not received

by the Care Coordinator within 15 calendar days from the date of the RFI letter, the service or good shall

be denied by the MCO.

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If the Care Coordinator or MCO identify an administrative error on the submitted SDCB care plan a

“Request for Administrative Action” (RFA) shall be sent to the Support Broker. The RFA shall specify what

is needed to correct the administrative error. The Support Broker must respond to the RFA within five

calendar days from the date of the RFA notification. If the RFA is not addressed by the Support Broker or

Care Coordinator within five calendar days from the date of the RFA letter, the service or good shall be

denied by the MCO/UR

The MCO will notify the member, Care Coordinator, and Support Broker in writing when a determination

has been made on the Care Plan. The determination may be a full approval, a partial approval, or a full

denial. The MCO shall indicate which goal(s) of the Care Plan have been approved or denied in

FOCoSonline. Written notifications will include steps for the SDCB member/legal representative to

follow if the member disagrees with a denial decision.

The FMA will utilize the approved care plan/budget to process payment for the approved amount of

SDCB services and related goods.

The member’s Care Plan must be approved before SDCB services can begin. The MCO will not issue

payment for any services, supports and/or related goods which are provided or purchased prior to the

approval of the Care Plan, or before the provider is linked to the Care Plan.

At the earliest opportunity, the Care Plan and the NF LOC shall be aligned to start/end on the same day.

This may entail truncating the existing SDCB care plan to align with the annual NF LOC or truncating the

existing NF LOC to align with the annual SDCB care plan.

9.15. Annual SDCB Budget Determination and Approval Process

Approximately 90 calendar days prior to the expiration of the existing SDCB care plan/budget, the Care

Coordinator shall conduct the annual CNA. The Care Coordinator shall assign the budget based on the

assessed needs identified in the CNA. The budget is determined annually, and the budget amount may

differ from year to year. The budget shall not be higher than the cost of care for persons served in a

private NF, unless the member transitioned into SDCB with their prior approved self-directed budget.

Unused budget amounts from a previous year cannot be carried over to the new SDCB care plan year.

Approximately 90 days prior to the expiration of the existing care plan/budget, the Support Broker shall

open the new Working Plan shell in FOCoSonline, with the begin and end dates for the upcoming SDCB

Care Plan. Upon the annual SDCB budget determination, the Care Coordinator shall enter the SDCB

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budget amount in FOCoSonline, allowing the member and Support Broker to begin developing the

upcoming year’s Care Plan.

9.16. Annual SDCB Care Plan Development and Approval Process

At a minimum, the Care Plan must be developed and submitted to the MCO for review annually, and no

less than 30 calendar days prior to the expiration of the existing care plan/budget. This 30 calendar day

timeframe allows enough time for the Care Coordinator and MCO to make an informed and accurate

determination of all requested services before the existing care plan/budget expires. The MCO will

notify the member, Care Coordinator, and Support Broker in writing when a determination has been

made on the Care Plan request. The determination may be a full approval, a partial approval, or a full

denial. The MCO shall indicate which goal(s) of the Care Plan have been approved or denied in

FOCoSonline and a letter shall be sent to the member including written instructions for the

member/legal representative to follow if the member disagrees with the denial decision(s).

9.17. SDCB Budget and Care Plan Approval Process for Individuals Who Transitioned from the MI VIA

Waiver Program

Prior to 1/1/2014, the Mi Via TPA approved many Mi Via employees/vendors at a reimbursement rate

which was above the maximum Mi Via rate for a particular Mi Via service. The higher reimbursement

rates are to continue to be approved in SDCB so long as the specific EOR and SDCB provider relationship

does not encounter a break in service. If, for any reason, the relationship ends and a new

employee/vendor is hired, the SDCB reimbursement rate for the new provider shall not exceed the

current approved SDCB range of rates (9.22.1) for any SDCB covered service. When the aforementioned

situation occurs, the budget may be reduced by the corresponding amount, if the SDCB member has no

other legitimate SDCB need(s).

Although Related Goods are not a covered service in ABCB, the need for “continuity of care” exists for

Related Goods. When redetermining the annual SDCB budget for SDCB members who transitioned from

the Mi Via waiver program, the MCO CC/UM shall allow the currently approved related good(s) and

previously approved reimbursement rate to be requested and approved, as deemed appropriate, for

each ongoing year of the SDCB care plan/budget.

At each annual assessment and budget determination, the Care Coordinator shall determine if the

member has underutilized his/her current SDCB care plan/budget. Underutilization is defined as using

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less than 75% of the total budget by the end of quarter three of the member’s current Care Plan year. If

underutilization has occurred, the Care Coordinator shall consider reducing the budget by an amount

which is no more than the approved total for the underutilized service for the upcoming care plan

year/budget. However, if underutilization is due to, for example, a temporary hospital admission, and if

the hospital admission had not occurred, the member would have utilized SDCB services as requested

and approved, the Care Coordinator may not adjust the budget for the upcoming care plan year/budget.

If overutilization of the Care Plan/budget is identified at any time during the care plan/budget year, the

MCO shall not increase the current budget and level of services without identifying the need for a new

CNA, and determining whether all other available resources have been exhausted. Overutilization is

defined as using more than: 1) 50% of the budget by the end of quarter two of the member’s current

care plan year; 2) 75% of the budget by the end of quarter three of the member’s current care plan year;

or 3) 100% of the budget by the end of quarter four of the member’s current Care Plan year.

Underutilization and overutilization of the budget may result in an involuntary termination from the

SDCB to ABCB depending on the situation; please refer to the SDCB involuntary termination policy.

9.18. Denials, Revisions and Reconsiderations of the SDCB Care Plan

• Denials:

The MCO shall send final decisions to the member in writing, including steps for the member/legal

representative to follow if he/she disagrees with the denial decision and wants to pursue a

reconsideration and/or the MCO appeal process. The MCO appeal process must be exhausted prior

to the member requesting a State Fair Hearing.

• Revisions:

The Care Plan may be revised based upon a change in the member’s needs or circumstances

identified in the CNA, such as a change in the member’s health status or condition, or a change in

the member’s natural support system such as the death or disabling condition of a family member

or other individual who was providing services.

If the revision is to provide new or additional services other than those originally included in the

Care Plan, these services must not be able to be acquired through other programs or sources. The

member may be required to document the fact that the services are not available through another

source. The Care Coordinator and/or Support Broker shall assist the member with exploring other

available resources.

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The member must provide written documentation of the change in needs or circumstances as

specified in the Manual. The member submits the documentation to the Care Coordinator/Support

Broker. In FOCoSonline, the member or the member’s legal representative and the Support Broker

initiate the process to modify the Care Plan by developing a revision in FOCoSonline and forwarding

the completed request for a care plan revision to the Care Coordinator who will submit the revision

to the MCO/UR for review, via FOCoSonline. At the MCO’s discretion, another CNA may be

performed. Per the SDCB rule, if the revision includes a request for additional services, another CNA

must be performed to determine whether the change in needs or circumstances necessitate an

increase to the budget.

The Care Plan may be revised once the original care plan has been submitted and approved. Only

one Care Plan revision may be submitted at a time, for example, a Care Plan revision may not be

submitted if an initial Care Plan or prior Care Plan revision request is under initial review by the

MCO/UR.

Other than for critical health and safety reasons, Care Plan revision requests may not be submitted

to the MCO within the last 60 calendar days prior to the expiration date of the current Care Plan

/budget. This constraint does not apply to environmental modifications requests, as environmental

modification work is not tied to a specific care plan year and the funding is not part of the overall

SDCB budget amount.

Anytime a member exits SDCB and transfers to ABCB, another Medicaid waiver such as the DD

Waiver, or is permanently institutionalized, the Support Broker must develop a close-out budget to

coincide with the last day the member will receive SDCB services. The only time a close-out budget is

not needed is when a member’s Care Plan will expire in the same month as the member’s final

month in SDCB. The close-out budget must be reviewed/approved by the MCO.

• Reconsiderations:

If the Care Plan, or a part of the Care Plan, is not approved, the Care Coordinator and/or Support

Broker assists the member to explore his/her options, including the right to request a

reconsideration of the denial decision. Reconsideration requests must be submitted to the MCO

within 30 calendar days of the date on the denial notice. Reconsideration requests must be made by

the Support Broker through FOCoSonline and additional documentation or additional clarifying

information must be submitted in writing regarding the member’s request for reconsideration of the

denied services or related goods.

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9.19. SDCB Care Plan Review Criteria

Services and related goods identified in the member’s requested Care Plan may be considered for

approval if all the following requirements are met:

• The services or related goods must be responsive and directly related to the member’s qualifying

condition or disability;

• The services or related goods must address the member’s clinical, functional, medical or habilitative

needs;

• The services or related goods must accommodate the member in managing his/her household;

• The services or related goods must facilitate ADLs;

• The services or related goods must promote the member’s personal health and safety;

• The services or related goods must afford the member an accommodation for greater

independence;

• The services or related goods must support the member to remain in the community and reduce

his/her risk for institutionalization;

• The services or related goods must be documented in the member’s Care Plan and facilitate the

desired outcomes stated in the member’s Care Plan;

• The service or related good is not prohibited by Federal and State statutes, rules and guidance;

• Each service or good must be listed as an individual line item; when services or related goods must

be “bundled” the Care Plan must document why bundling is necessary and appropriate;

• The proposed Care Plan is within the member’s approved budget;

• The proposed rate for each service is within the SDCB range of rates (9.22.1) for that chosen service;

• The proposed cost for each good is reasonable, appropriate and reflects the lowest available cost for

that chosen good; and

• The estimated cost of the service or good is specifically documented in the member’s Care Plan.

9.20. Implementation of the SDCB Care Plan

• Enrolling SDCB Employees and Vendors:

o Pre-Hire Packet:

▪ Before providing services to a member, most employees and vendors are required to submit

the appropriate State-approved pre-hire packet to the FMA and pass the COR screening. The

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exception to this requirement is when the vendor has a professional license, such as an RN

or Speech Language Pathologist (SLP) that qualifies them to provide the approved service.

The FMA is responsible for maintaining, distributing and processing the pre-hire packets. For

answers to questions about hiring employees or vendors and to obtain the pre-hire packet,

an EOR shall contact the FMA Help Desk at 1-866-916-0310;

▪ Potential SDCB employees are required by New Mexico law through the caregivers’ criminal

history screening act (7.1.9 NMAC) to pass a CBC which begins by screening against the COR.

This COR screening is completed by the FMA, usually within 48 hours, once the complete

and correct pre-hire packet is received by the FMA. Once the COR check is completed, and

the potential SDCB provider has passed the COR check, the EOR will receive an email

notification from the FMA that the potential SDCB employee has passed his/her COR and

CBC and may begin providing SDCB services. If the EOR does not have an email address

listed in FOCoSonline, the FMA Help Desk will contact the EOR, via telephone to let the EOR

know that the potential SDCB employee has passed the COR check. Although an employee

may begin providing services as soon as he/she has passed the COR Background Check,

payment will not be issued until all required paperwork as indicated below is successfully

completed and has been approved by the FMA. If a potential SDCB employee or vendor

does not pass the CBC, as required by New Mexico law, he/she may not continue to provide

services to the SDCB member. The potential SDCB employee or vendor and FMA will be

notified by the Department of Health if he/she does not pass the CBC. The FMA will notify

the SDCB member/EOR when a potential SDCB employee has or has not successfully

completed the COR check and/or CBC; and

▪ No SDCB provider shall exceed 40 hours paid work in one work week per EOR. If an

employee works for more than one EOR, the employee shall not exceed 40 hours paid work

in one work week, per EOR.

o Credentialing Requirements:

▪ The State has set credentialing requirements for credentialing providers of SDCB services,

and these requirements have been approved by CMS. The FMA shall ensure these

requirements are met. These requirements include certain licenses which must be

submitted by the potential SDCB provider to the FMA, and are described in 9.B & 9.C

(Vendor and Employee Credentialing Requirements). Services cannot be provided to a

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member until the SDCB care plan is approved, and there is a credentialed and approved

provider linked to the approved SDCB goal.

o Other Required Documents:

▪ There are other documents that must be correctly completed by the potential SDCB

employee or vendor and submitted to the FMA for review and approval before payment can

be made. Potential SDCB employees and vendors may obtain these documents by

contacting the FMA. It is the member/EOR’s responsibility to ensure all employment

documents are submitted to the FMA.

For potential SDCB employees, the required documents are included in the Employee Packet:

• Employment Agreement;

• Employee Information Form;

• Declaration of Relationship Form;

• Federal W-4; and

• State W-4.

For potential SDCB vendors who are providing services the required documents are included as part of

the Vendor Packet:

• Vendor Agreement;

• Vendor Information Form; and

• Federal W-9.

Vendors who are providing SDCB related goods only (such as a large retailer) do not need to provide the

Vendor Agreement and Federal W-9, however the SDCB member/EOR or vendor must submit the

Vendor Information Form to the FMA before payment is issued.

Direct deposit is provided and strongly recommended for all employees and vendors when possible. The

FMA also offers the service of providing payment through a ComData Card. Please contact the FMA if

interested in using this service. Direct deposit forms can be completed as part of the initial hire

documentation or may be completed and submitted to the FMA at a later date.

• Purchasing Services and Related Goods:

o Timesheets:

▪ ASDCB employee (or EOR) must enter and approve the employee(s)’s timesheet(s) in

FOCoSonline unless he/she is approved for an exception to fax timesheets to the FMA. Upon

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completing the FOCoSonline training, a new user will receive a FOCoSonline Account

Authorization form (via email). Once the new user completes the FOCoSonline Account

Authorization form and faxes it to the FMA Technical Department, the user will receive an

email with his/her password and login instructions;

▪ Timesheets are submitted and processed on a two-week pay schedule according to the

SDCB Payroll Payment Schedule. The payroll workweek starts on Saturday and ends the

following Friday. The payment schedule is available through the FMA and on the MCOs’

websites. Timesheets are due at the end of the two- week pay period and must be received

at the FMA no later than Saturday at 11:59 pm for a SDCB employee to be paid on time and

according to the payment schedule; and

▪ An AR may also complete the training and gain access to FOCoSonline. If an AR has access,

they will be able to view payments and monitor SDCB budget spending, however, the AR will

not have authorization to perform the functions of the EOR and approve timesheets. To

designate an AR, members must complete the AR form, which may be requested through

the FMA or the Support Broker.

▪ Self-Directed Personal Care and Respite providers must utilize the EVV system to clock-in

and out in order to generate a timesheet in FOCoSonline or other state approved system.

o Invoices:

▪ Vendor PRF and invoices may be submitted to the FMA on any day of the week (unlike

timesheets which must be submitted according to the payroll schedule). The processing

time for a PRF/invoice is approximately two weeks. The vendor payment schedule is

available through the FMA. Vendor checks are generated by TeleCheck and are mailed

directly to the EOR (payments are not mailed to the vendor). After the EOR receives the

vendor check, it is recommended that the EOR mail/deliver the check to the vendor as soon

as possible to ensure prompt payment. For phone/internet payments, the EOR must send

the payment to the phone/internet company’s main billing address (with the payment

coupon). It is not recommended that phone/internet payments be attempted through

kiosks or at local phone/internet stores (e.g., T-Mobile or Cricket) since these payments are

frequently rejected by TeleCheck. Uncashed checks may be voided by the FMA after six

months; and

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▪ Although an EOR must submit timesheets online (after completing necessary FOCoSonline

training and paperwork), it is not possible to submit invoices online. PRFs and invoices must

be faxed or sent electronically to the FMA for processing. If a SDCB member/EOR has access

to FOCoSonline, he/she should review his/her payments and monitor them as they are being

processed. In addition, the SDCB member, EOR, or AR may run reports through FOCoSonline

to monitor spending activity.

o Return to Member (RTM) Process:

▪ RTM letters are an effective means used by the FMA to assist in communicating with the

EOR when there are problems in processing SDCB payment. For example, if a timesheet or

invoice is submitted to the FMA and it does not contain the appropriate signatures, the FMA

uses the RTM process to inform the EOR that payment cannot be made. In addition to the

RTM letter which is mailed, the FMA attempts contact with the EOR by phone. If three

unsuccessful phone call attempts to the EOR have been made and the corrected document

still has not been received, the FMA will send an email to the EOR (provided the EOR has an

email address in FOCoSonline) with a copy to the Care Coordinator and Support Broker. If

the EOR does not have an email address in FOCoSonline, the FMA will send an email to the

Care Coordinator and Support Broker and attach a copy of the RTM letter. Since frequent

contact is attempted by the FMA to the EOR, it is extremely important that FOCoSonline

contain the EOR’s correct contact information. If the EOR contact information needs to be

updated, please contact the FMA Help Desk for assistance.

o Employee and Vendor Pay Rates:

▪ Employee and vendor pay rates must be approved in the member’s care plan. Once the

SDCB rate is approved, completed employee agreements and vendor agreements must be

submitted to the FMA in order to indicate the rate of pay. If a potential SDCB employee or

vendor does not submit an employee or vendor agreement, as appropriate, the FMA will

not know the correct rate of pay for the service that the employee or vendor is providing. In

order for the FMA to pay a SDCB employee or vendor, a completed employee agreement or

vendor agreement needs to be submitted to, and approved by, the FMA and the

employee/vendor must be linked to the SDCB goal inside FOCoSonline. If the pay rate for an

approved SDCB employee or vendor needs to be changed, the new rate must be approved

by the MCO via a SDCB care plan revision in FOCoSonline and in the member’s SDCB care

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plan and a new employee agreement or vendor agreement, signed by the EOR, must be

submitted to the FMA at least 15 calendar days before the effective date of the rate change.

If a change to a SDCB employee’s rate of pay is made after the SDCB care plan has started,

the change will not be effective until the beginning of the next pay period.

o Timely Filing Requirements:

▪ New Mexico has a 90 calendar day time limit for filing all Medicaid claims and since the

SDCB is a Medicaid benefit, the same requirements apply. If timesheets or invoices are

submitted more than 90 calendar days after the service has been provided, payment will not

be processed and the timesheet or invoice and PRF will be returned to the EOR/member

through the RTM process.

o SDCB Care Plan Expenditure Safeguards:

▪ The SDCB member holds the primary responsibility for monitoring and ensuring his/her

approved SDCB care plan is spent appropriately; however, the Care Coordinator and Support

Broker must support the SDCB member in this activity. The FMA also assists in ensuring that

funds are spent appropriately through payment of approved services and related goods

according to the approved SDCB care plan and Employee/Vendor Agreements;

▪ The member/EOR is responsible for reviewing his/her monthly spending report which is

available to each member/EOR by the FMA on a monthly basis. The SDCB member/EOR may

also obtain “real-time” information on service usage and spending by directly accessing

FOCoSonline. It is highly recommended that members/EORs obtain access to FOCoSonline so

that they can effectively monitor their care plan/budget and track spending. Monthly

training for FOCoSonline is offered for SDCB members, employees, and EORs. If interested in

training, the SDCB member, employee, or EOR should contact the FMA Help Desk for

assistance;

▪ The Support Broker is required to review the member’s SDCB care plan expenditures during

each quarterly face-to-face contact with the member. The Care Coordinator and/or Support

Broker will provide the member with expenditure information and discuss any concerns. If

the member needs to revise his/her SDCB care plan, the Support Broker shall assist with

drafting the revision and the Care Coordinator will submit it to the MCO/UR for

consideration per established procedures. The Care Coordinator may also initiate a new CNA

as needed; and

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▪ The FMA is responsible for processing payments for approved SDCB services and related

goods. When an invoice or timesheet is received by the FMA, they verify that the particular

service or good is approved in the member’s SDCB Care Plan/budget and payment is

processed according to the approved SDCB Care Plan/budget and employee/vendor

agreement. In regards to internet and phone services (landline or cell), the FMA will pay up

to the approved monthly amount. This helps to ensure that this category of service is not

overspent which could put the member at-risk of losing these services due to possible

non-payment later in the SDCB Care Plan year. If the FMA is unable to make payment as

requested due to lack of funds remaining in the Care Plan, the FMA will send an RTM letter

to the member and make three attempts to contact the member by telephone to inform the

EOR/member of the insufficient funds issue.

9.21. Transitions, Terminations, and Reinstatement Processes

Upon initial eligibility for the CB, the member will be eligible for the ABCB. An ABCB member may choose

to move to SDCB at any time but may not move to SDCB until the first day of the month after 120

calendar days are completed in the ABCB. The member must utilize CB services in the ABCB prior to

transitioning to SDCB. If the member has a short-term admission to an NF, the 120 calendar days does

not start over. The member must always end the current CB model on the last day of the month and

start the new CB model on the first day of the following month. The Care Coordinator must ensure there

is no break in CB services during model switches. Examples of transition for members who enter an NF

include, but are not limited to, the following:

• The member only has a waiver COE (090, 091, 092, 093 or 094) and is institutionalized more than 60

days, the member must apply for IC and submit their name back on the Central Registry. They then

must receive a Community Reintegration allocation. If, when they are discharged, they still have

living arrangements in place, they are not required to complete the 120 days in ABCB again;

• If the member does not have living arrangements in place, the member must go back to ABCB

during the transition and is not mandated to complete another 120 days in ABCB. Meaning, the

member can begin self-directing after all living arrangements have been set up and the member is

successfully in that living arrangement and the SDCB budget, Care Plan and employees are approved

to provide SDCB-covered services; and

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• If the member has a full Medicaid COE (001, 003, 004, etc.) and is institutionalized for more than 60

days and the member does not have living arrangements still in place, the member must go back to

ABCB during the transition and is not mandated to complete another 120 days. Meaning, the

member can begin self-directing after all living arrangement have been set up and the member is

successfully in that living arrangement and the SDCB budget, Care Plan and employees are approved

to provide SDCB-covered services.

Voluntary Termination

• SDCB members may transfer from the SDCB to the ABCB at any time. To the extent possible, the

SDCB member shall provide his/her SDCB provider(s) with 10 business days advance notice

regarding his/her intent to withdraw from the SDCB. All transfers will become effective on the 1st

day of the following month.

Involuntary Termination

• Reasons SDCB members may be involuntarily terminated from the SDCB and offered services

through the ABCB include, but are not limited to, the following circumstances:

o The SDCB member refuses to follow SDCB rules after receiving: focused technical assistance on

multiple occasions; and support from the program staff, Care Coordinator/Support Broker, or

FMA that is supported with documentation of the efforts to assist the SDCB member. Focused

technical assistance is defined as a minimum of three separate occasions where the member

/EOR have received training, education or technical assistance, or a combination of both;

o The SDCB member has immediate risk to his/her health or safety by continued self-direction of

services, e.g., the SDCB member is in imminent risk of death or serious bodily injury related to

participation in the SDCB. Examples include, but are not limited to, the following:

▪ The SDCB member refuses to include and maintain services in his/her SDCB Care Plan that

would address health and safety issues identified in the member’s CNA or challenges the

assessment after repeated and focused technical assistance and support from program

staff, Care Coordinator/Support Broker, or FMA;

▪ The SDCB member is experiencing significant health or safety needs, and, after having been

referred to the State contractor team (that includes the appropriate State program manager

and additional parties as deemed necessary by the State) for technical assistance, refuses to

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incorporate the team’s recommendations into his/her SDCB Care Plan, or the SDCB member

exhibits behaviors which endanger him/her or others;

▪ The SDCB member misuses SDCB funds following repeated and focused technical assistance

and support from the Care Coordinator/Support Broker or FMA, which is supported by

documentation;

▪ The SDCB member expends his/her entire SDCB budget prior to the end of the SDCB Care

Plan year;

▪ The SDCB member commits Medicaid fraud such as, for example, altering SDCB

employee/vendor payment checks;

▪ The final decision to terminate a SDCB member and move him/her to ABCB is made by the

State. The MCO shall submit sufficient documentation to the State for approval of the

involuntary termination request. Upon State approval, the MCO shall notify the member of

the involuntary termination, in writing, and shall include appeal rights per HSD rules. The

MCO must transition the member to the ABCB with no break in services. The transition must

be completed within 90 calendar days of the date of HSD approval. SDCB involuntary

terminations may become effective any time during the month;

▪ Requests to be reinstated back to SDCB may be made one time during a 12-month period.

The member must make the request to his/her MCO in writing. All members shall be

required to participate in SDCB training prior to their reinstatement;

▪ A SDCB member who voluntarily terminated his/her participation in SDCB may request to

move back from ABCB to SDCB any time during a 12-year month period. The final decision to

allow the reinstatement to SDCB is at the discretion of the MCO. The Care Coordinator must

ensure the transition does not cause a break in services; and/or

▪ A SDCB member who was involuntarily terminated from SDCB may request to be reinstated

to SDCB once per 12-month period. The final decision to allow the reinstatement to SDCB is

at the discretion of the State. The MCO shall submit sufficient documentation to the State

for approval of reinstatement to the SDCB. If approved, the Care Coordinator shall work

with the FMA to ensure the issues previously identified as reasons for termination have

been adequately addressed prior to the reinstatement.

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January 1, 2019; October 1, 2020

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9.22. Appendices

9.22.1 SDCB Range of Rates Chart

9.22.2 SDCB Vendor Credentialing Requirements

9.22.3 Employee Credentialing Requirements Grid

9.22.4 Vendor Toolkit

9.22.5 Employee Toolkit

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9.22.1. SDCB Range of Rates Chart

SDCB Service

Billing

Code

Internal

Focos Code

Unit

SDCB Payment

Rate

Self-Directed Personal Care

99509

Hour

minimum wage

- $14.60

HH Aide

S9122

Hour

$16.32

Employment Supports (includes Job Coach)

T2019

15 min.

$2.15 - $6.93

Job Developer (Per job that is developed for member)

T2019

T2019JD

Each

$100-$700

Customized Community Supports (adult day hab.)

S5100

15 min.

$1.36-$8.82

G0151

15 min.

$13.51 - $24.22

G0152

15 min.

$12.74 - $23.71

Speech/Language Pathology

G0153

15 min.

$16.06 - $24.22

Behavior Support Consultation

H2019

15 min.

$12.24 - $20.65

Private Duty Nursing – Adults- RN

T1002

15 min.

$10.90

Private Duty Nursing – Adults- LPN

T1003

15 min

$6.79

Nutritional Counseling

S9470

Hour

$42.83

Acupuncture

97810

15 min.

$12.50-$25.00

Biofeedback

90901

Visit

$50.00-$100.00

Chiropractic

98940

Visit

$50.00-$100.00

Cognitive Rehabilitation Therapy

97532

15 min.

$12.50-$25.00

Hippotherapy

S8940

Visit

$50.00-$100.00

Massage Therapy

97124

15 min.

$12.50-$25.00

Naprapathy

S8990

Visit

$50.00-$100.00

Native American Healers

S9445

Session

As approved by MCO

Respite Standard (not provided by RN, LPN or HHA)

T1005

T1005SD

15 min.

$3.38

Respite RN

T1005

T1005RN

15 min.

$10.90

Respite LPN

T1005

T1005LPN

15 min.

$6.79

Respite HH Aide

T1005

T1005HHA

15 min.

$4.08

Emergency Response (monthly fee)

S5161

Each

$36.71-$40.79

Emergency Response (testing and maintenance)

S5160

Each

As approved by MCO

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SDCB Service

Billing

Code

Internal

Focos Code

Unit

SDCB Payment

Rate

Environmental Modifications

S5165

Each

As approved by MCO

(maximum of $5,000

every 5 years)

Transportation Mile

T2049

Per Mile

$0.34-$.40

Transportation Commercial Carrier Pass

T2004

Each

As approved by MCO

Start Up-Goods Computer

T2028

T2028CR

Each

As approved by MCO

Start Up-Goods Fax Machine

T2028

T2028FX

Each

As approved by MCO

Start Up-Goods Internet Activation

T2028

T2028IA

Each

As approved by MCO

Start Up-Goods Landline Activation

T2028

T2028LA

Each

As approved by MCO

Start Up-Goods Office Supplies

T2028

T2028OS

Each

As approved by MCO

Start Up-Goods Printer

T2028

T2028PR

Each

As approved by MCO

Fees and Memberships

T1999

T1999CP-I

Each

As approved by MCO

Coaching/education for parents, spouse or others

(not available for paid caregivers)

T1999

T1999CE-I

Each

As approved by MCO

Coaching/education for parents, spouse or others

Classes only (not available for paid caregivers)

T1999

T1999CL-I

Each

As approved by MCO

Coaching/education for parents, spouse or others

Conferences and seminars (not available for paid

caregivers)

T1999

T1999CS-I

Each

As approved by MCO

Technology for Safety and Independence

T1999

T1999TS

Each

As approved by MCO

Cell phone service (including data/GPS)

T1999

T1999CELL

Each

$0.00-$100.00

Cell phone and related equipment

T1999

T1999CPEP

Each

As approved by MCO

Cell phone/landline

T1999

T1999CPL

Each

As approved by MCO

Internet service

T1999

T1999IS

Each

As approved by MCO

Landline service

T1999

T1999LS

Each

As approved by MCO

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SDCB Service

Billing

Code

Internal

Focos Code

Unit

SDCB Payment

Rate

Internet/cell phone

T1999

T1999IC

Each

As approved by MCO

Internet/cell phone/landline

T1999

T1999ICL

Each

As approved by MCO

Internet/landline

T1999

T1999IL

Each

As approved by MCO

Fax machine

T1999

T1999FX

Each

As approved by MCO

Computer

T1999

T1999CR

Each

As approved by MCO

Office supplies

T1999

T1999OS

Each

As approved by MCO

Printer

T1999

T1999PR

Each

As approved by MCO

Health-related equipment and supplies

T1999

T1999HR-I

Each

As approved by MCO

Adaptive equipment and supplies

T1999

T1999AE-I

Each

As approved by MCO

Exercise equipment and related items

T1999

T199EE-I

Each

As approved by MCO

Nutritional supplements

T1999

T1999NS-I

Each

As approved by MCO

OTC medications

T1999

T1999OM-I

Each

As approved by MCO

Household related goods

T1999

T1999HG-I

Each

As approved by MCO

Appliances for independence

T1999

T1999AI-I

Each

As approved by MCO

Adaptive furniture

T1999

T1999AF-I

Each

As approved by MCO

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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9.22.2. SDCB Vendor Credentialing Requirements

Requirements for enrolling SDCB Vendors

Before using any Vendor, please call Conduent (1-866-916-0310) to ensure all required vendor paperwork has been processed and the vendor

has been set up on your SDCB Care Plan. If you use a vendor before their paperwork has been processed, they will not be paid for those DOS.

All enrollment requirements (with the exception of the final CBC) must be processed before services can be provided. Services that are provided

prior to enrollment will not be paid by Medicaid or Conduent.

If a vendor provides only related goods (not services), you will only need to complete the Vendor Information Form (you do not need to

complete the entire Vendor Packet). We use the Vendor Information Form to show that you will be using this vendor on your Plan. Since vendors

that provide related goods are usually large companies (for example: CenturyLink, Comcast, Wal-Mart, K-Mart, Best Buy), it is not necessary to

get their signature on the form. If you are not sure whether you are purchasing a “good” or a “service,” please call Conduent for assistance.

Vendors (Independent Contractors and Agencies) that provide Services

Ag = Agency, IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

97810

Acupuncture

Allowed Providers: Group Practice or Individual Specialized Therapist

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License

IC: Acupuncture and/or oriental medicine license

H2019

Behavior Support Consultation

Allowed Providers: Individual BSC or BSC Group Practice

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License

IC: Licensed (MD, Clinical Psychologist, Psychologist

Associate, SW, LPCC, LPC, Psychiatric Nurse, New Mexico

LMFT, New Mexico LPAT)

90901

Biofeedback

Allowed Providers: Group Practice or Individual Specialized Therapist

Visit

Agency: Yes

IC: Yes

Agency: Business License

IC: License in Health Care Profession whose scope of

practice includes Biofeedback

98940

Chiropractic

Allowed Providers: Group Practice or Individual Chiropractor

Visit

Agency: Yes

IC: Yes

Agency: Business License

IC: Chiropractic Physician License

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Vendors (Independent Contractors and Agencies) that provide Services

Ag = Agency, IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

T1999CE-I

Coaching Education for Parents, Spouse or Other

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

Agency: Business License IC: Pre-Hire Packet

T1999CS-I

Coaching Education for Parents/Spouse: Conferences & Seminars ONLY

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999CL-I

Coaching Education for Parents/Spouse: Classes ONLY

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

97532

Cognitive Rehabilitation Therapy

Allowed Providers: Group practice or Individual Specialized Therapist

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License

IC: License in Health Care Profession whose scope of

practice includes Cognitive Rehabilitation Therapy

S5100

Customized Community Support

Allowed Providers: Adult Day Health Agency or Adult Day Habilitation

Agency

Per 15 min

Agency: Yes

Agency: Business License

S5160

Emergency Response Testing and Maintenance

Allowed Providers: Emergency Response Provider (Agency)

Each

Agency: No

Agency: Business License

S5161

Emergency Response Monthly Service Fee

Allowed Providers: Emergency Response Provider (Agency)

Monthly

Agency: No

Agency: Business License

T2019

Employment Supports (includes Job Coach)

Allowed Providers: Supported Employment Provider Agency or

Individual

Each

Agency: Yes

IC: Yes

Agency: Business License IC: Pre-Hire Packet

S5165

Environmental Modifications

Allowed Providers: Individual or Company (Agency)

Each

Agency: Yes

IC: Yes

Agency: Appropriate License IC: Appropriate License

T1999CP-I

Fees and Memberships

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999HR-I

Health-Related Equipment and Supplies

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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Vendors (Independent Contractors and Agencies) that provide Services

Ag = Agency, IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

T1999AE-I

Adaptive Equipment and Supplies

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999EE-I

Exercise Equipment and Related Items

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999NS-I

Nutritional Supplements

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999OM-I

OTC Medications

Allowed Providers: Vendor

Each

Agency: No

Yes IC: No

VIF is required (goods only)

S8940

Hippotherapy

Allowed Providers: Group Practice or Individual Specialized Therapist

Visit

Agency: Yes

IC: Yes

Agency: Business License

IC: License in Healthcare profession whose scope of

practice includes Hippotherapy.

S9122

Home Health Aide

Allowed Providers: HHA/PCS Agency

Hour

Agency: Yes

Agency: Business License

99509

Self-Directed Personal Care

Allowed Providers: Individual Self-Directed Personal Care Provider or

HHA/PCS Agency

Hourly

Agency: Yes

IC: Yes

Agency: Business License IC: Pre-Hire Packet

T1999HG-I

Household Related Goods and Services Item/Invoice

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999AI-I

Appliances for Independence Item/Invoice

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999AF-I

Adaptive Furniture Item/Invoice

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T2019JD

Job Developer

Allowed Providers: Supported Employment Provider Agency or

Individual

Each

Agency: Yes

IC: Yes

Agency: Business License IC: Pre-Hire Packet

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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Vendors (Independent Contractors and Agencies) that provide Services

Ag = Agency, IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

97124

Massage Therapy

Allowed Providers: Group Practice or Individual Specialized Therapist

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License

IC: Massage Therapist License

S8990

Naprapathy

Allowed Providers: Group Practice or Individual Specialized Therapist

Visit

Agency: Yes

IC: Yes

Agency: Business License

IC: Naprapathic Physician License

S9445

Native American Healers

Allowed Providers: Group Practice or Individual Specialized Therapist

Session

IC: Yes

IC: Pre-Hire Packet

S9470

Nutritional Counseling

Allowed Providers: Group Practice or Individual

Hourly

Agency: Yes

IC: Yes

Agency: Business License

IC: Registered Dietician License

G0152

Occupational Therapy

Allowed Providers: Individual Occupational Therapist or Group Practice

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License IC: OT License

G0151

Physical Therapy

Allowed Providers: Group Practice or Individual Physical Therapist

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License IC: PT License

T1003

Private Duty Nursing LPN

Allowed Providers: HHA, RHC, FQHC or Individual

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License IC: LPN License

T1002

Private Duty Nursing RN

Allowed Providers: HHA, RHC, FQHC or Individual

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License IC: RN License

T1005HHA

Respite Home Health Aide

Allowed Providers: Respite Agency

Per 15 min

Agency: Yes

Agency: Business License

T1005SD

Respite Standard

Allowed Providers: Individual Provider (not RN, LPN or HHA) or Respite

Provider Agency

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License IC: Pre-Hire Packet

T1005LPN

Respite LPN

Allowed Providers: Respite Provider Agency or Individual LPN

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License IC: LPN License

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Vendors (Independent Contractors and Agencies) that provide Services

Ag = Agency, IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

T1005RN

Respite RN

Allowed Providers: Respite Provider Agency or Individual RN

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License IC: RN License

G0153

Speech/Language Pathology

Allowed Providers: Individual SLP or Group Practice

Per 15 min

Agency: Yes

IC: Yes

Agency: Business License IC: RN License

T2028CR

Start-Up Goods- Computer Purchase

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T2028FX

Start-Up Goods - Fax Machine Purchase

Each

Agency: No

IC: No

VIF is required (goods only)

T2028IA

Start-Up Goods - Internet Activation

Each

Agency: No

IC: No

VIF is required (goods only)

T2028LA

Start-Up Goods - Landline Activation

Each

Agency: No

IC: No

VIF is required (goods only)

T2028OS

Start-Up Goods – Office Supplies (purchased as items)

Each

Agency: No

IC: No

VIF is required (goods only)

T2028PR

Start-Up Goods – Printer Purchase

Each

Agency: No

IC: No

VIF is required (goods only)

T1999TS

Technology for Safety and Independence

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999CR

Computer Purchase (item)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999PR

Printer Purchase (item)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999FX

Fax Machine Purchase (item)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999CPEP

Cell Phone and Related Equipment Purchase (item)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

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Vendors (Independent Contractors and Agencies) that provide Services

Ag = Agency, IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

T1999IS

Internet Service

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999CELL

Cell Phone Service

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999LS

Landline Service

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999ICL

Internet/Cell Phone/Landline Service (bundled)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999IC

Internet/Cell Phone Service (bundled)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999IL

Internet/Landline Service (bundled)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999CPL

Cell Phone/Landline Service (bundled)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T1999OS

Office Supplies (purchased as items)

Allowed Providers: Vendor

Each

Agency: No

IC: No

VIF is required (goods only)

T2004

Transportation Commercial Carrier Pass

Allowed Providers: Transportation Commercial Carrier

Each

Agency: No

IC: No

VIF is required (goods only)

T2049

Transportation Mile

Allowed Providers: Transportation Agency or Individual Driver

Per Mile

Agency: Yes

IC: Yes

Agency: Business License

IC: Transportation Appendix, Pre-Hire Packet

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If the vendor has a professional license (such as an RN or therapist), their licensing board has already completed a background check. Provider

agencies are responsible for completing CBC on all their staff. Confirmation of the CBC must be available to the State and Conduent for review as

requested.

Please remember that at the beginning of each SDCB Care Plan year (annual renewal), new Vendor Agreements are required for any vendor

providing services. If Conduent does not receive a Vendor Agreement before your new Plan starts, your vendor will not be set up on your new

Plan and they may be paid late. Please call Conduent (1-866-916-0310) before your new SDCB Care Plan starts to ensure all your SDCB providers

are set up for payment.

The above grid provides an overview of general vendor credentialing requirements. In certain specific cases, additional licensing or other

documentation may be required.

Please contact Conduent (1-866-916-0310) or your Support Broker if you have any questions.

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9.22.3 Employee Credentialing Requirements Grid

SELF-DIRECTED

COMMUNITY BENEFIT SERVICE

Service

Code

*Pre-Hire

Packet

**Employee

Packet

Transportation

Appendix

Employment Supports (includes Job Coach)

T2019

Yes

Self-Directed Personal Care

99509

Yes

Respite – Standard

T1005SD

Yes

Transportation Mile

T2049

Yes

*Pre-Hire Packet: Division of Health Improvement (DHI) form, copy of identification card, and three

fingerprint cards.

**Employee Packet: Employee Information Form, Employee Agreement, Transportation Appendix (if

performing driving services), Declaration of Relationship, W-4 (Federal and State), I-9 Form, Direct

Deposit Authorization Form (optional).

Helpful Reminders

•

Employer of Record (EOR) documentation must be completed and approved before an employee’s

enrollment can be approved and before an employee can begin work.

•

Employees may not begin working until they have passed their initial COR Background Check (this is

included in the Pre-Hire Packet).

•

Employees cannot be paid until their entire Employee Packet has been successfully processed.

•

In order to drive, an employee must have current vehicle registration and insurance in the

employee’s name.

•

Please remember that Employees must complete a new Employee Agreement for each Plan year. If

Conduent does not receive an Employee Agreement before the beginning of the new Plan, the

employee may not get paid on time.

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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9.22.4. Vendor Toolkit: Invoices

Toolkit: Invoices

Use these tips for completing Invoices!

Q: What is this toolkit for?

A: This toolkit explains how to make the invoice process work smoothly! Members,

Employers and Vendors can work together to help make sure invoices get processed

and paid on time.

Keys to Getting Paid the Correct Amount, On Time!

Follow these tips to avoid delayed payment of your invoice.

•

Be sure ALL vendor paperwork has been completed and submitted.

•

Effective July 15, 2011, invoices that are received by Conduent (formerly Xerox)

more than 90 days after the service was provided, will not be processed for

payment. According to Medicaid timely-filing requirements, we cannot process any

request for payment that has not been submitted within 90 days from the date the

vendor performed the service. This means that all invoices with a PRF, must be

submitted to Conduent no later than midnight on the 90th

day after services have

taken place. Any invoices with a PRF that are submitted after this time limit will not be

paid by Conduent and will be returned to you. Also, if you need to make corrections to

your invoice and/or PRF, you must complete them within this timeframe (90 days

from the date the service was performed).

•

Follow the CURRENT Vendor Payment Schedule.

Keep a copy of the Vendor Payment Schedule in front of you. If you submit your

invoice and PRF after the deadline on Saturday, your vendor payment may be

delayed.

Note: The deadline for submitting invoices is always on a Saturday by midnight

(before 12:00 am on Sunday).

•

Use your legally registered business name.

For example,

o Smith Industries, LLC is your legally registered business name with State of New

Mexico. This is the name you must use on your invoice and PRF!

Bobby Smith is your personal name. Do not use!

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January 1, 2019; October 1, 2020

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Smith Wheelchair Repair is a name you sometimes use to refer to your company

but it is not your legal name. Do not use!

•

Submit invoices and PRFs for monthly service codes after the service is complete.

If the service is monthly, you must wait until after midnight on the last day of the month.

If the service is hourly, you must wait until you have finished working on that day. For

example, if you finish working at 3:00 pm, you cannot submit your invoice and PRF until

3:01 pm on the same day. The general rule is: you cannot enter, submit or sign an invoice

for services not yet rendered.

•

Use correct units on invoices

For example, if the rate for service is in 15 minute increments, you must enter the

invoice charge in 15 minute increments. Do not combine amounts into hourly.

•

Only the vendor can make a correction to an invoice

Corrections to an invoice cannot be handwritten unless the invoice to be corrected is

handwritten. We will not accept invoices if white-out appears to have been used or if

changes appear to have been made by anyone other than the vendor.

•

You can use your own invoice form, but…

Your invoice must include the same level and type of detail shown on the invoice (see

below.) This detail is required for legal and auditing purposes and to ensure you get paid

correctly and on time.

•

Send in the PRF

The PRF must also be submitted (in addition to the invoice). This applies whether it is you

or the Employer who typically sends in the PRF and invoice. (The Employer is responsible

for making sure that the PRF and invoice are sent in.)

•

Fax your invoice.

Only fax your PRF and invoice one time unless you are faxing a corrected invoice. If it is a

corrected invoice, check the box Yes for “Is this a correction to a PRIOR Invoice?” Re-faxing

the same PRF and invoice or forgetting to check the “Corrected” box on the PRF for a

corrected invoice will cause delays in a check being issued. The fax number is

1-866-302-6787. This applies whether it is you or the Employer who typically faxes in the

invoice (the Employer is responsible for making sure the PRF and invoice are faxed in.

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Invoice for Non-Timesheet Provider Agency/Contractor

FAX: 1-866-302-6787 MAIL: CONDUENT PO Box 27460, Albuquerque, NM 87125

Section 9: Self-Directed Community

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9.22.5. Employee Toolkit: Timesheets

Toolkit: Timesheets

Q: What is this toolkit for?

A: This toolkit explains how to make the timesheet process work smoothly! Members, Employers

and Employees can work together to help make sure timesheets get processed and paid on

time.

TIPS FOR GETTING PAYCHECKS THAT ARE ACCURATE AND ON TIME!

•

Be sure ALL employee paperwork has been completed & submitted.

•

Effective July 15, 2011, timesheets that are received by Conduent (formerly Xerox) more than

90 days after the service was provided will not be processed for payment. According to

Medicaid timely-filing requirements, we cannot process any request for payment that has not

been submitted within 90 days from the date the employee worked. This means that all

timesheets must be submitted to Conduent (via fax or the FOCoSonline system) no later than

Midnight on the 90th

day after services have taken place. Any timesheets that are submitted

after this time limit will not be paid by Conduent and will be returned to you.

Also, if you need to make corrections to your timesheets, you must complete them within this

timeframe (90 days from the date the employee worked).

•

Follow the CURRENT payroll periods.

Keep a copy of the payroll schedule in front of you. Timesheets submitted after Saturday’s

deadline may result in a delayed paycheck. If you would like a copy of the current Payroll

Payment Schedule, please contact the Self-Direction Help Desk (1-866- 916-0310).

Note: For Employers that have been approved by the MCO for online timesheet exceptions, the

deadline for submitting timesheets by fax is always on the Saturday by Midnight (before 12:00

am on Sunday) at the end of the pay period. Online timesheets must be approved in

FOCoSonline by the Employer by 12:00 pm (noon) Tuesday after the end of the pay period.

•

Service dates on all timesheets need to be ON or BEFORE the last day of the timesheet

period.

You cannot enter, submit or sign a timesheet for work not yet performed. For example, if the

pay period ends on Friday, May 20th, you cannot enter time for services you will provide on

Monday, May 23rd

even if the services are generally similar or the same.

Section 9: Self-Directed Community

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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•

Services Provided field on the Timesheet.

Enter descriptions of tasks and services provided to the member.

•

Timesheets need to be complete and correct (see example on Page 3 of this toolkit).

•

Both the Employee and the Employer need to sign and date the timesheet.

•

Fax your timesheet if you are on the MCO approved exception list.

Only fax your timesheet one (1) time unless you are faxing a corrected timesheet or if you have

been asked to refax it. If it is a corrected timesheet, check the box Yes for “Is this a correction

to a PRIOR Timesheet?” Not following these guidelines can cause delays in a check being

issued. The fax number is 1-866-302-6787.

•

Use the exact same name on your timesheet as used for your employee paperwork.

For example, if you completed paperwork as William J Smith and you enter Billy Smith on your

timesheet, we won’t know who you are. This will cause a delay in getting paid.

Section 9: Self-Directed Community

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January 1, 2019; October 1, 2020

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Section 10: RESERVED

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

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10. RESERVED

Section 11: Marketing

Revision dates: August 15, 2014; March 3, 2015;

October 1, 2020

Effective dates: January 1, 2014

298 | P a g e

11. Marketing

11.1. General Information

This policy establishes guidelines and restrictions for all MCOs awarded a contract and subcontractors of

the MCO, or under contract with HSD to deliver health care services, for marketing and outreach

activities referencing the managed care program.

Definitions

Health Education: Programs, services or promotions designed or intended to advise or inform the

MCO’s enrolled members about issues related to healthy lifestyles, situations that affect or influence

health status, behaviors that affect or influence health status or methods of medical treatment.

Health Educational Materials: Materials designed, intended, or used for health education or outreach to

the MCO’s enrolled members. Health education materials include, but are not limited to:

condition-specific brochures, letters or phone calls, member newsletters, posters and member

handbooks.

Incentives: Items used to encourage behavior changes in the MCO’s enrolled members or health

promotion incentives used to motivate members to adopt a healthy lifestyle and/or obtain specific

health care services. These may include but are not limited to:

• Infant car seats or baby item giveaways;

• Gift cards;

• Manufacturer or coupons for savings on products; or

• Services or any other objects designed or intended to be used in health education or outreach.

Incentives may not be used in conjunction with the distribution of alcohol or tobacco products, or

firearms.

Marketing: Any medium of communication that is written, audio/oral, personal face-to-face, or

electronic, including any promotional activities, intended to increase the MCO’s or subcontractor’s

membership or to “brand” an MCO’s or subcontractor’s name or organization.

Marketing Materials: General audience materials such as general circulation of brochures, flyers,

newspaper, phone book advertisements, websites and/or any other materials designed, intended, or

used for increasing the MCO’s or subcontractor’s membership or establishing a brand. Such marketing

materials may include but are not limited to scripts, provider directories, leaflets, posters, billboards, or

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any material that is distributed or circulated by the MCOs and subcontractors, including providers

(e.g., personal care providers).

Outreach: Any means of educating or informing the MCO’s enrolled members about health issues. See

also Health Education.

Outreach Materials: Materials designed, intended, or used for health education or outreach purposes

only for the MCO’s enrolled members. See also Health Education.

Event Promotion: Any activity in which any approved marketing materials are given away or displayed

with the intent to provide health education and/or outreach.

Provider: A hospital/hospital staff, physician/physician staff, pharmacy/pharmacist, ancillary service

providers and their staff, personal care/homemaker providers and their staff.

Policy

Marketing is information intended for the general public about the existence of the MCO and its

subcontractors and the availability of the MCO as an enrollment option for people deemed eligible for

services through Centennial Care.

Outreach is communication with enrolled members for the purpose of member retention and improving

the health status of enrolled members. Retention efforts must be directed to currently enrolled

members who are determined to be at risk for attrition or be based on analysis of membership trends

such as decreased utilization of preventative services.

The MCO must submit marketing, outreach, retention activities and materials to HSD for review and

prior approval. In addition, the MCO must provide HSD with an electronic copy of the approved

materials, advertising copy or publication in which the ad will be placed. All member materials must be

mailed to members unless the member requests the material in an alternative format.

• Marketing Material Approval

The MCO shall submit electronic versions of all written materials that will be distributed to members

(referred to as member materials) to HSD’s Communication and Education Bureau’s Marketing

Coordinator and copy the HSD contract manager for review and approval. This includes but is not limited

to member handbooks, provider directories, member newsletters, member identification cards and,

upon request, any other additional, but not required, materials and information provided to members

designed to promote health and/or educate members.

• All member materials must be submitted to HSD in electronic file media, in the format

prescribed by HSD. The MCO shall submit the reading level and the methodology used to

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measure it concurrent with all submissions of member materials and include a plan that

describes the MCO’s intent for the use of the member materials.

• The HSD Marketing Committee will attempt to approve or deny marketing requests within 15

business days of the receipt of the complete request. The 15 business day timeframe for

approval or denial shall only apply to the specific date of the initial submission. Modifications of

any type would need to be resubmitted, which may delay approval.

• Prior to modifying approved member materials, the MCO shall submit to HSD for prior written

approval a detailed description of the proposed modifications in accordance with this section of

the Manual.

• The use of any material, including those that pertain to incentives, marketing, outreach, and

promotions must have prior approval from the HSD Marketing Committee.

• Materials that have been previously approved, but will be included in a specific activity must

also be included in the MCO’s submission for review and approval by HSD.

• MCOs shall review all material on a regular basis and revise materials as necessary. Any revised

or updated material previously approved must be submitted to HSD for approval.

• HSD Review of MCO Materials

The MCO shall ensure all materials submitted to HSD for review meet the following criteria:

o All materials shall include information that describes what the submission is, its purpose and

what population (if applicable) it will target. This information may be submitted in form of a

cover letter, MCO Contractor plan form, or in the body of an email;

o All materials consisting of two or more pages must be numbered;

o All materials must be 6th grade reading level or lower and each submission must provide the

reading level with and without, proper names, medical terminology, etc.;

o All materials must indicate if a translated version will be made available to the member or how

the member can request a translated version;

o All materials must be submitted timely and at least 30 calendar days prior to use allowing the

HSD Marketing Committee at least 15 business days to review. If an “expedited” review is

needed, please submit and allow at least five business days for review and approval or request

special accommodations for unique circumstances;

o All materials used for any type of Medicaid or managed care training purposes must be

submitted for review and approval before training occurs (i.e., handouts, PowerPoint

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presentations, etc.). If MCOs are collaborating and conducting one training using the same

PowerPoint presentation, one MCO should be designated to submit the material on behalf of all

MCOs (e.g. Annual Tribal Meetings);

o All materials shall identify the MCO as an HSD/MAD managed care provider and are consistent

with all the requirements for information to members described in the Agreement, regulations

and the Manual;

o All materials shall specify “Such services are funded in part with the State of New Mexico”;

o All related materials should be submitted to HSD for review together, in lieu of separate

submissions;

o All approved materials shall be provided in electronic format to the HSD marketing coordinator

in the English and translated Spanish version (if applicable); and

o Outreach material may not include the words: “free”, “join”, “enroll”, “sign up” or similar

verbiage unless approved by the HSD Marketing Committee. If the MCO intends on using such

language in any of the materials, the request for approval must include how the message is

related to an Outreach goal.

• Events

MCOs may participate in health-related marketing and outreach events. Events must be health-related

or have health education components. MCO participation in these events must be substantive; an

unmanned booth(s) with handouts is not acceptable.

The MCO shall submit to the HSD Marketing Committee all marketing outreach events in which the MCO

participated. Participation includes, but is not limited to, having a manned booth at the event, financially

contributing to the event, and/or having a presence at the event.

• Marketing and Outreach Plan

The MCO shall submit an annual Marketing and Outreach Plan as well as a quarterly report which

outlines the MCO’s activities.

• MCO Health Plan Name and Logos

MCO Name and Logos can be included on event flyers or websites that are produced by hosting

organizations without prior approval. MCO must monitor their MCO name and logo use to prevent

misuse. Small giveaway items such as, but not limited to, pens, pencils, balls, toys, etc. that are only

identified by the addition of the MCO’s logo do not need prior approval from HSD.

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Any items that include the MCO’s logo as well as any reference to Centennial Care or the State Medicaid

program must be approved by HSD through the Marketing approval process.

• Restrictions

The following restrictions apply to all marketing, outreach and retention activities. The following shall

not be allowed:

o Incentive items such as t-shirts, buttons, balloons, key chains, etc. unless the intent of such a

give-away is outreach in nature (i.e., for educating members about benefits of safety,

immunizations, well-care, or as a “reward/incentive” for member accessing care as part of an

approved incentive program);

o Solicitation of any individual face-to-face, door-to-door or cold call telemarketing, including that

of the MCO’s subcontractors;

o Any reference to competing plans;

o Promotional materials, incentives, or any other activity to influence enrollment in conjunction

with the sale or offering of any private insurance;

o Unsolicited direct mail advertising, including that of the MCO’s subcontractors;

o Marketing of non-covered services;

o Reference to the word “free” for any covered service;

o Use of HSD/MAD logo;

o Inaccurate, misleading, confusing, or negative information about HSD, or statements designed

to recruit potential members, including that of the MCO’s subcontractors;

o Discriminatory marketing practices; and/or

o The MCO may not encourage or persuade the member to select a particular MCO plan or

subcontracted provider when completing specific applications or forms. The MCO or its

subcontractor may not complete any portion of the application forms on behalf of the potential

enrollee. The prohibition covers all situations, whether sponsored by the MCO, its parent

company, or any other entity.

HSD reserves the right to impose additional restrictions at any time.

• Sanctions/Penalties

Any violation of this policy may result in the sanctions as described in 7.3 of the Agreement.

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The MCO shall ensure subcontractors are advised that they must comply with this policy. All materials

must be submitted by all subcontractors to the MCO for review and approval based on the MCO specific

policies and procedures for marketing.

Failure of a subcontracted provider to adhere to this policy may result in sanctions/penalties to the

contractor contracted with such a provider.

Subcontractors may only advertise the services they provide and may not make any reference to

HSD/MAD programs, Medicaid or services the MCO provides.

o Temporary Sanctions/Penalties

Any activities or materials found in violation of this policy will be subject to sanction regardless of

previous approval or terms in contractual agreements. The MCO contractor will be placed on

“Moratorium” status and will not be allowed to advertise via the following:

▪ Television advertising;

▪ Internet advertising;

▪ Print advertising;

▪ Radio advertising;

▪ Billboards; and

▪ Bus wraps (including bus stops).

The MCO will monitor its subcontractors found in violation of this policy and impose sanctions for

marketing or advertising of the subcontractor’s services and/or business.

The HSD Marketing Review Committee will review the “Moratorium” status on an annual basis, or at

HSD’s discretion, to determine if the MCO or its subcontractor is deemed compliant.

• References

o 42 CFR 438.104, 42 CFR 438.10, 42 CFR 431.12, 42 CFR 431.307

o HSD/MAD Medicaid Managed Care Services Agreement

Section 12: Patient Centered Initiatives

Revision dates: August 15, 2014; March 3, 2015;

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12. Patient-Centered Initiatives

12.1. Broad Standards

The MCO shall establish patient-centered initiatives based on the National Committee for Quality

(NCQA), Joint Commission on Accreditation of Healthcare Organizations, (JCAHOJCAHO) or Accreditation

Association for Ambulatory Health Care (AAAHC) PCMH recognition programs.

The MCO shall develop patient-centered, “whole person” models of care that are uniform across payers

and tailored to the diverse needs and capacities of primary care practices, large and small, urban, rural

and frontier. The New Mexico model should be based upon nationally accepted standards.

This model will be a blended model building upon the work already completed by practices that have

achieved certification programs. A blended model will include a pathway toward certification for those

practices that do not currently have the capacity to attain certification.

The New Mexico PCMH program will provide technical assistance, benchmarks, and financial support to

practices in order to move them along the pathway towards national recognition. Payment to

New Mexico PCMH practices is standardized and based on the level of PCMH achievement and

continued evidence of quality care to patients and reduced cost. The New Mexico PCMH will include

State-specific goals tailored to the unique needs of communities and patients.

Core components of the New Mexico PCMH Model include:

• Administrative:

o Adopt a standard model for PCMH that includes national certification by NCQA, AAAHC, and

JCAHO;

o Develop a “Glide Path” to certification that is open to all practices seeking PCMH status;

o Provide technical assistance and hands on training for practices working towards PCMH

certification; and

o Simplify, coordinate and standardize practices across MCOs specifically: claims, prior

authorizations, and other administrative processes.

• Clinical:

o Improved access to care through flexible scheduling, accommodating walk-ins, utilization of

telemedicine, providing after hours and weekend office hours;

o Provider teams collaborate with community health workers, lactation consultants, public health

workers, and other community members;

o Integration/co-location of BH services, MH, and substance use including SBIRT;

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o Include school-based health centers and other non-traditional healthcare settings; and

o Engage patients in their own health care decisions, respect for patient values, and culture and

inclusion of patient care givers.

• Coordination of care:

o Develop a care coordination collaborative that operates across payers at the point of care (in

the health care office or other community location);

o Prioritize communities of highest need;

o Address social determinants of health (i.e., housing, food, transportation, etc.);

o Seamless transition between services and providers; and

o Integration of public health services, including but not limited to: Children’s Medical Services

care coordination for children with special health care needs, Women Infants and Children,

sexually transmitted infection (STI) treatment, and contact tracing, etc.

• Data:

o Build provider capacity through support for evidence-based programs;

o Facilitate partnerships with supporting entities such as the Primary Care Association to help

develop tools for providers;

o Facilitate data sharing that provides optimal use of data for improving member outcomes; and

o Commitment to data integration and sharing information to improve collaborative efforts to

improve quality and lower costs, and to improve population health.

• Payment:

o While the MCO is not required to enter into VBP reimbursement arrangements with PCMHs,

the MCOs are expected to implement VBP strategies to promote quality and improve health

care outcomes in alignment with the Centennial Care contractual requirements;

o Align value-based payments with patient health care outcomes and achievement of quality

metrics; and

o Standardize a payment approach for PCMH that includes practices that have not yet attained

certification but are working on improving quality, access, and other core components of

PCMH.

• Specific Actions Related to Policy:

o Support Tribal 638 programs to become FQHCs under 330.

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13. ABP Medically Frail and ABP Exempt

13.1. General Information

This section of the Manual is issued to address the criteria and process for determining whether a

member in the Other Adult Group COE 100 is medically frail. A medically frail member in COE 100 may

choose to continue receiving services under the ABP services package or may choose to become ABP

exempt and receive services under the Medicaid State Plan benefit package.

ABP exempt means an Other Adult Group Medicaid (COE 100) recipient who has been determined as

meeting the definition and criteria of medically frail (as defined in Section 13.2. of the Manual) and has

chosen to receive services under the Medicaid State Plan benefit package instead of the ABP. All COE

100 members are notified of their enrollment in the ABP and of the medically frail exemption

criteria/process on their HSD Medicaid eligibility notice. The eligibility notice also directs ABP recipients

to the HSD/MAD website where they can find the full listing of ABP benefits and a comparison to the

Medicaid State Plan. This section of the Manual explains the detailed criteria that should be used by the

MCO to determine whether COE 100 members meet one of the definitions of medically frail.

13.2. Determination of Medically Frail Diagnosis

Members in COE 100 may self-identify to the MCO by telephone that they may be medically frail and

may do so at any time during their eligibility for COE 100. Members in COE 100 may also be identified as

potentially medically frail by the MCO through the care coordination process.

To determine whether a member qualifies as medically frail, the MCO should reference the Medically

Frail Conditions List. The member must have a documented medical diagnosis from the list of qualifying

conditions. A written statement from a licensed provider attesting to the medical condition will suffice.

The entire medical record is not needed. If obtaining a written statement will cause significant delay, the

MCO may confirm the diagnosis by a licensed provider over the telephone. If the diagnosis is confirmed

by telephone, the MCO should document the discussion occurred and the outcome of that conversation.

The MCO should determine which staff can perform this function. A nurse is not required.

There shall be no end date for a medically frail approval. Upon the member’s self-identification, or

through the MCO’s care coordination process, the MCO shall evaluate and confirm whether the member

qualifies as medically frail. The MCO shall confirm the member’s status and notify the member whether

they meet the criteria for ABP exempt by mail within 10 business days of the member’s

self-identification. If the MCO is unable to obtain a provider’s diagnosis or any requisite follow-up from

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either the member or a provider after making a good faith effort to do so within the necessary

timeframe, the MCO should issue a denial letter to the member.

The ABP member remains enrolled in the ABP until the MCO has confirmed medically frail status and the

member has chosen to receive the ABP exempt benefit package. The MCO shall describe the benefit and

cost-sharing differences between the ABP and the full Medicaid benefit package, if requested by the

member.

13.3. ABP Exempt Approval

If the member chooses the ABP exempt benefit package, the MCO shall make the indication in Omnicaid

using a Disability Type Code of ME (for an SMI, substance use disorder [SUD], or other mental disability)

or PH (for a PH disability) within two business days of receiving a call from a medically frail COE 100

member choosing the ABP Exempt benefit package; and shall mail the ABP Exempt member an approval

letter. The entry in Omnicaid should be made in the Client Detail window in the Client Subsystem and

may be made at any time during the month.

If the member does not meet medically frail criteria, the MCO shall mail the member a denial letter.

Should the member disagree with the MCO’s determination about his/her ABP Exempt status, the

member may file a reconsideration or request a fair hearing through the MCO’s appeals process. If a

member does not have one of the conditions or diagnoses listed on the Medically Frail Conditions List

and the member believes that his/her condition should be considered for inclusion, a request may be

sent to HSD/MAD to include the condition. The HSD/MAD Medical Director will review the request to

determine whether the individual’s condition should be added.

13.4. Appendices

13.4.1 ABP Benefit Chart

13.4.2 Alternative Benefit Plan-Exempt Medically Frail Conditions List

13.4.3 Chronic Substance Use Disorder (SUD) Criteria Checklist

13.4.4 Serious Mental Illness (SMI) Criteria Checklist

13.4.5 SMI-SED Criteria

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13.4.1. ABP Benefit Chart

Medicaid ABP 1-8-2014

Recipient Definitions

Note there are 2 types of ABP recipients. The ABP recipient: The recipient is COE 100, but does not have

a disability indicator of PH or ME. The charts below are only applicable to the ABP recipient category.

ABP Exempt: The recipient is COE 100 but also has a disability indicator of PH or ME, meaning either a

PH or MH disability, or other condition that qualifies the recipient as medically frail.

When an ABP recipient’s condition is evaluated and it is determined they meet the qualifying conditions,

they may choose to become an “ABP Exempt” recipient. The benefit package of an ABP Exempt recipient

changes from the standard ABP recipient to that of the “standard” Medicaid full benefit recipient. That

is, the ABP benefit package ends and the ABP Exempt recipient then has access to the same benefits as a

full standard Medicaid recipient.

The COE of the recipient remains 100 with a PH or ME indicator to distinguish them in the various

computer systems. Because the benefits of an ABP-Exempt recipient become the same as any other

standard full benefit Medicaid recipient, we do not list their benefits in this chart.

The term “ABP recipient” always means an ABP recipient who is not ABP exempt. If the recipient is exempt

(and therefore eligible for the standard Medicaid full benefit services) the recipient is always referred to

as an “ABP Exempt recipient”.

Once the recipient becomes an ABP Exempt recipient, they are not subject to any of the service limits

associated with ABP. They do not retain any of the additional services found only in the ABP (primarily

preventive services). If the ABP Exempt recipient is enrolled in an MCO, the MCO extends the same

benefits and managed care services to the ABP Exempt recipient provided to the full benefit Medicaid

recipient.

An ABP Recipient has the following benefits equivalent to those of standard Medicaid Benefits:

professional services and treatments, including services at FQHC’s and other clinics; inpatient and

outpatient hospital services; equipment and devices; laboratory and radiology; and transportation).

The coverage of the following services or providers of services under the ABP is essentially the same that

for the standard Medicaid full benefit population and, therefore, would be covered by an MCO to the

same extent an MCO covers and provides services to traditional full Medicaid eligible recipients. The list

is intended to be used to communicate the general scope of the services. Not every provider and service

is described:

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• Physician and most practitioner services and visits, including maternity service, surgeries,

anesthesia, podiatry, etc., that are available for traditional full Medicaid eligible recipients;

• BH and substance abuse services, evaluations, assessments, therapies, including all the various

forms of therapy such as Comprehensive Community Support Services that are available for

traditional full Medicaid eligible recipients:

o Specialized BH services for children: the MCO must ensure BH and substance abuse services

provided to EPSDT recipients are available to ABP recipients ages 19 and 20;

o Specialized BH services for adults: The specialized BH services for adults are Intensive

Outpatient, Assertive Community Treatment, and Psychosocial Rehabilitation. These three

services are included in the ABP;

o Services not included in the ABP: The following services are not included in the ABP plan

because they are considered more in the area of supportive waiver-type services and are not

State Plan services: Family Support, Recovery Services, and Respite Services; and

o Electroconvulsive therapy: This is a benefit under ABP, but not as a State Plan service for

standard service.

• Cancer trials, chemotherapy, IV infusions, and reconstructive surgery services that are available for

traditional full Medicaid eligible recipients;

• Dental services as available for traditional full Medicaid eligible recipients. An EPSDT recipient must

have available the increased frequency schedule of oral exams every six months and orthodontia

(when medically necessary) for 19 and 20 year olds per EPSDT rules;

• Diabetes treatment including diabetic shoes;

• Dialysis;

• DME, oxygen, and supplies necessary to use other equipment such as for oxygen equipment,

ventilators and nebulizers, or to assist with treatment such as casts and splints that are applied by

the healthcare practitioner;

• Family planning, sterilization, pregnancy termination, contraceptives;

• Hearing testing or screening as part of a routine health exam. ABP does not cover the hearing aids

and does not typically cover audiologist’s services or any services by a hearing aid dealer, except for

EPSDT children, ages 19 and 20, for whom testing and hearings aids are covered;

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• Hospice services — If the hospice recipient requires NF LOC, the recipient will have to meet the

requirements for receiving NF care;

• Hospital inpatient, outpatient, urgent care, emergency department, outpatient free-standing

psychiatric hospitals, inpatient units in acute care hospitals for rehabilitation or psychiatric, and

rehabilitation specialty hospitals:

o Free-standing psychiatric hospitals are only covered for EPSDT children (therefore, up through

age 20) for FFS recipients. However, MCOs continue to pay for inpatient free-standing

psychiatric hospitals for adults; and

o Inpatient drug rehabilitation services are not an ABP benefit. Acute inpatient services for

“detox” are an ABP covered benefit.

• Immunizations, mammography, colorectal cancer screenings, pap smears, prostate-specific antigen

(PSA) tests, and other age appropriate tests that are available for traditional full Medicaid eligible

recipients;

• Inhalation therapy;

• Lab including diagnostic testing, and colorectal cancer screenings, pap smears, PSA tests, and other

age appropriate tests that are available for traditional full Medicaid eligible recipients;

• Lab genetic testing to specific molecular lab tests such as breast cancer susceptibility gene (BRCA)1

and BRCA2 and similar tests used to determine appropriate treatment, not including random genetic

screening;

• Medication assisted treatment (substance abuse treatment including methadone programs and

suboxone);

• Ob-gyn, prenatal care, deliveries, midwives;

• Orthotics (note foot orthotics including shoes and arch supports are only covered when an integral

part of a leg brace, or are diabetic shoes);

• Podiatry services are available to the same extent as for traditional full Medicaid eligible recipients.

(coverage is similar to Medicare);

• Prescription drug items (but not over the counter [OTC] items, except for prenatal drug items

(examples include vitamins, folic acid, iron), low dose aspirin as preventative for cardiac conditions;

contraception drugs and devices, and items for treating diabetes. OTC items are covered for ages 19

and 20);

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• Prosthetics are available to the same extent as for traditional full Medicaid eligible recipients;

• Radiology including diagnostic imaging and radiation therapy, including mammography and other

age appropriate imagining;

• Reproductive health services are available to the same extent as for traditional full Medicaid eligible

recipients;

• Telemedicine;

• Tobacco cessation counseling that are available for traditional full Medicaid eligible recipients.

MCOs must cover tobacco cessation counseling beyond the Medicaid FFS coverage; and

• Transportation (emergency and non-emergency) including air and ground ambulance, taxi and

handivan.

The following services are not covered under the standard Medicaid benefits or the ABP and are not

required to be covered by the MCO for ABP members unless the MCO chooses to do so as VAS.

• Acupuncture;

• Infertility treatment;

• Naprapathy;

• Temporomandibular joint and crania mandibular joint treatment;

• Weight loss programs; and

• Any other service not covered by the standard Medicaid program unless specifically described as an

added benefit for ABP in this section.

Note also the ABP does not include the following:

• CBs;

• NF care, except as a temporary step down LOC from a hospital prior to being discharged to home;

and

• Mi Via.

However, if an ABP recipient becomes an ABP Exempt recipient, the recipient can access CBs, NF care,

and Mi Via when all the requirements to receive those services are met.

An ABP recipient has the following benefits similar to standard Medicaid recipients but with limitations.

These are services which are benefits for recipients under the standard Medicaid program, but which

have limitations to coverage under the ABP.

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Service

Limitations for ABP Recipients (COE 100) for Ages

21 and above

For Ages 19 and 20

Limitations do not apply to ABP

recipients (COE 100) who are Ages

19 or 20 because of EPSDT rules.

Recipients Under Age 19 Are Not

Enrolled In ABP

Bariatric surgery

Limited to 1 per lifetime.

Criteria may be applied that considers previous attempts

by the recipient to lose weight, BMI, health status, etc.

Covered under EPSDT if medically

necessary (perhaps unlikely) without the

lifetime limit.

Criteria may be applied that considers

previous attempts by the recipient to lose

weight, BMI, health status, etc.

Cardiac rehabilitation

Limited to 36 hours per cardiac event.

Covered under EPSDT if medically

necessary without the limit on hours.

Chiropractic

Not covered.

Covered under EPSDT if medically

necessary (this very rarely happens).

Drug items that do not

require a prescription

(OTC)

Not covered except for items related to prenatal care;

low dose aspirin for preventing cardiac events; treatment

of diabetes, items used for contraception (foams,

devices, etc.).

Coverage of diabetic test strips, and similar items are

described under medical supplies, below. An MCO may

choose to cover any OTC product when the OTC product

is less expensive than the therapeutically equivalent drug

that would require a prescription (a “legend” drug).

Covered using the same provisions as

for recipient under EPSDT in the

standard Medicaid program.

Glasses and contact

lens

Not covered except for aphasia (following removal of

the lens.) Eye exams and treatment related to eye

diseases and testing for eye diseases are a benefit, but

that the refraction component of the exam (a separate

code) is not a benefit.

Covered using the same provisions as

for children under EPSDT in the

standard Medicaid program.

Hearing aids

Not covered.

Hearing screening is covered, but only when part of a

routine health exam. Typically; additional separate

payment is not made for this part of the exam.

Hearing testing by an audiologist or a hearing aid dealer

is not a benefit.

Covered using the same provisions as

for children under EPSDT in the

standard Medicaid program.

HH services

Limited to 100 visits annually – a visit cannot exceed 4

hours.

An MCO has the option of providing these services through

private duty nursing and nursing registry personnel

Covered under EPSDT without the

limitation on the dollar amount or length

of visits.

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Service

Limitations for ABP Recipients (COE 100) for Ages

21 and above

For Ages 19 and 20

Limitations do not apply to ABP

recipients (COE 100) who are Ages

19 or 20 because of EPSDT rules.

Recipients Under Age 19 Are Not

Enrolled In ABP

Medical foods for

errors of inborn

metabolism, or as a

substitute for other

food for weight gain,

weight loss, or

specialized diets, for

use at home by a

recipient.

Not covered.

Covered using the same provisions as

for children under EPSDT in the

standard Medicaid program.

May be subjected to criteria that

assure medical necessity.

Disposable medical

supplies such as

diapers, under pads,

gauzes, gloves,

dressings,

colostomy supplies,

for use at home by a

recipient.

Not covered.

Except for diabetic supplies (reagents, test strips, needles,

test tapes, alcohol swabs, etc.).

However, supplies necessary to utilize oxygen or DME

such as administer oxygen, use nebulizer, clean tracheas

for ventilator use, or assist in treatments such as casts or

splints are covered.

Medical supplies used on an inpatient basis, applied as

part of a treatment in a practitioner’s office, outpatient

hospital, residential facilities, as a HH service, etc. are

covered though often these items are not paid

separately in addition to the payment for the overall

service.

When separate payment is allowed in these settings, the

items are considered covered.

Covered using the same provisions as

for children under EPSDT in the

standard Medicaid program.

May be subjected to criteria that

assure medical necessity.

Pulmonary

rehabilitation

Limited to 36 hours per year.

Covered under EPSDT without the

limitation on the number of visits.

Rehabilitation

and Habilitation

• PT

• OT

• SLP

Rehabilitative services for short-term physical,

occupational, and speech therapies are covered.

Short-term therapy includes therapy services that

produce significant and demonstrable improvement

within a two-month period from the initial date of

treatment.

Extension of short-term therapy beyond the initial two

months may be extended for one period of up to two

months, dependent on the approval of the MCO’S

medical director, only if such services can be expected to

result in continued significant improvement of the

member’s physical condition within the extension period.

Other than the above one-time extension, therapy

services extending beyond the two-month period from

the initial date of treatment are considered long-term

therapy and are not covered.

Covered under EPSDT without the

limitation on duration.

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Service

Limitations for ABP Recipients (COE 100) for Ages

21 and above

For Ages 19 and 20

Limitations do not apply to ABP

recipients (COE 100) who are Ages

19 or 20 because of EPSDT rules.

Recipients Under Age 19 Are Not

Enrolled In ABP

Extended care

hospitals (LTC

hospitals)

Extended care hospitals are not covered. Sometimes these

are referred to as LTC hospitals (certified as acute care

hospitals but focus on care for more than 25 days).

NF LTC stays are not covered by ABP except as a

temporary step down LOC following discharge from a

hospital prior to being discharged to home.

Covered under EPSDT without the

limitations.

Sleep studies

Not covered.

Covered under EPSDT.

Transplants

Limited to 2 per lifetime.

Covered under EPSDT without the dollar

amount limitation.

ABP benefits that may exceed the standard Medicaid Coverage are listed below. The following services

must be provided to ABP recipients, even though these services may not be covered for standard

Medicaid eligible recipients, but may already be required to be provided through an MCO to a member.

Service

Notes

Preventive care, annual physicals, etc.

Under preventive care, a large range of services are covered as part of or in addition

to the preventative care exam. See extended comments on the preventive services

at the end of this document.

Autism spectrum disorder

There are no age or dollar limits for Applied Behavioral Analysis (ABA) benefits.

Disease management

Electroconvulsive therapy

Educational materials and

counseling for a healthy lifestyle

Nutritional counseling

Skilled nursing

Skilled nursing is generally provided only through a HH agency under the Medicaid

FFS program.

However, an MCO can also provide skilled nursing through private duty nursing.

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Preventive care services, typical of what is found in a commercial insurance plan, are covered for ABP

recipients. Typically, this includes annual exams with all the components appropriate for the age,

condition, and history of the recipient as recommended by various physician specialty associations and

academies.

Additionally, for recipients who are aged 19 and 20, all of the screening and preventive services

available to this age group under the EPSDT provisions are benefits for both ABP recipients and ABP

Exempt recipients.

The requirements related to ABP include assuring the ABP population’s preventive care benefits include

the recommendations of the United States Preventive Services Task Force (USPSTF). These

recommendations are found at the following website:

https://www.uspreventiveservicestaskforce.org/

ABP coverage of preventive services is not intended to be to only those services on the list. Other

preventive services that are generally found in a commercial insurance plan would be covered. The list is

not intended to describe or replace the preventive screening and services available to EPSDT recipients.

The following list includes items that may need special attention or comment, but we have removed

items from the list that are routinely performed in hospitals at the time of birth (e.g., phenylketonuria

screening), and services for children for which the EPSDT screenings and service components are already

more comprehensive. When the website above is updated with new recommendations, those additions

and charges are considered to be part of the requirement.

Service

USPSTF Recommendations

Application to Medicaid

Abdominal aortic aneurysm

screening: men

One-time screening for abdominal aortic aneurysm by

ultrasonography in men ages 65 to 75 years who have

never smoked.

Technically a new requirement, but Medicaid

would not currently deny a claim for this

service.

Alcohol misuse: screening and

counseling

Clinicians screen adults age 18 years or older for alcohol

misuse and provide persons engaged in risky or

hazardous drinking with brief behavioral counseling

interventions to reduce alcohol misuse.

Technically a new requirement, but

practitioners would already be performing

this function during exams.

The counseling component does not have to

include any providers not currently covered

by the Medicaid program.

Anemia screening: pregnant

women

Routine screening for iron deficiency anemia in

asymptomatic pregnant women.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Aspirin to prevent

cardiovascular disease: men

The use of aspirin for men ages 45 to 79 years when the

potential benefit due to a reduction in myocardial

infarctions outweighs the potential harm due to an

increase in gastrointestinal hemorrhage.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

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Service

USPSTF Recommendations

Application to Medicaid

Aspirin to prevent

cardiovascular disease: women

The use of aspirin for women ages 55 to 79 years when

the potential benefit of a reduction in ischemic strokes

outweighs the potential harm of an increase in

gastrointestinal hemorrhage.

Covered – already in managed care coverage

requirements or as a standard.

Medicaid recipient State Plan service.

Bacteriuria screening: pregnant

women

Screening for asymptomatic bacteriuria with urine

culture in pregnant women at 12 to 16 weeks' gestation

or at the first prenatal visit, if later.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Blood pressure screening in

adults

Screening for high blood pressure in adults age 18 years

and older.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

BRCA screening, counseling

about

Women whose family history is associated with an

increased risk for deleterious mutations in BRCA1 or

BRCA2 genes be referred for genetic counseling and

evaluation for BRCA testing.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Breast cancer preventive

medication

Clinicians discuss chemoprevention with women at high

risk for breast cancer and at low risk for adverse effects

of chemoprevention. Clinicians should inform patients

of the potential benefits and harms of

chemoprevention.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Breast cancer screening

Screening mammography for women, with or without

clinical breast examination, every 1 to 2 years for

women age 40 years and older.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Breastfeeding counseling

Interventions during pregnancy and after birth to

promote and support breastfeeding.

At this time, based on comparison with

commercial plans MAD interprets this as

instruction or counseling that would occur

during the routine prenatal care and

postpartum care; and possibly assessed for

any issues or lack of success by the

pediatrician treating the newborn.

Cervical cancer screening

Screening for cervical cancer in women ages 21 to 65

years with cytology (Pap smear) every 3 years or, for

women ages 30 to 65 years who want to lengthen the

screening interval, screening with a combination of

cytology and human papillomavirus testing every 5

years.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Chlamydial infection screening:

non-pregnant women

Screening for chlamydial infection in all sexually active

non-pregnant young women age 24 years and younger

and for older non-pregnant women who are at increased

risk.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Chlamydial infection

screening: pregnant women

Screening for chlamydial infection in all pregnant women

age 24 years and younger and for older pregnant women

who are at increased risk.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Cholesterol abnormalities

screening: men 35 and older

Screening men age 35 years and older for lipid disorders.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

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Service

USPSTF Recommendations

Application to Medicaid

Cholesterol abnormalities

screening: men younger than

Screening men ages 20 to 35 years for lipid disorders if

they are at increased risk for coronary heart disease.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Cholesterol abnormalities

screening: women 45 and

older

Screening women age 45 years and older for lipid

disorders if they are at increased risk for coronary heart

disease.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Cholesterol

abnormalities

screening: women

younger than 45

Screening women ages 20 to 45 years for lipid disorders

if they are at increased risk for coronary heart disease.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Colorectal cancer screening

Screening for colorectal cancer using fecal occult blood

testing, sigmoidoscopy, or colonoscopy in adults

beginning at age 50 years and continuing until age 75

years. The risks and benefits of these screening methods

vary.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Depression screening: adults

Screening adults for depression when staff-assisted

depression care supports are in place to assure accurate

diagnosis, effective treatment, and follow-up.

Covered – already in managed care coverage

requirements.

The “depression care supports” component

does not have to include any provider types

not currently covered by the Medicaid

program.

Diabetes screening

Screening for Type 2 Diabetes in asymptomatic adults

with sustained blood pressure (either treated or

untreated) greater than 135/80 mm Hg.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Falls prevention in older

adults: exercise or PT

Exercise or PT to prevent falls in community-dwelling

adults age 65 years and older who are at increased risk

for falls.

At this time and based on comparison with

commercial plans, MAD interprets this as

detection of the issue during routine annual

preventive care exams, and referring as

necessary.

The referrals might be to community

programs, home use of TV and DVD

programs, etc. We do not believe the

requirement is to pay for the exercise class or

PT.

Falls prevention in older

adults: vitamin D

Vitamin D supplementation to prevent falls in

community- dwelling adults age 65 years and older who

are at increased risk for falls.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Folic acid

supplementation

All women planning or capable of pregnancy take a

daily supplement containing 0.4 to 0.8 mg (400 to 800

µg) of folic acid.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

318 | P a g e

Service

USPSTF Recommendations

Application to Medicaid

Healthy diet counseling

Intensive behavioral dietary counseling for adult

patients with hyperlipidemia and other known risk

factors for cardiovascular and diet-related chronic

disease. Intensive counseling can be delivered by

primary care clinicians or by referral to other specialists,

such as nutritionists or dietitians.

Coverage of this benefit exceeds the

coverage currently found in Medicaid rules. It

may include covering additional providers

when there is a referral.

May be performed by a physician, dietician,

or other qualifying practitioner

Hepatitis B screening: pregnant

women

Screening for Hepatitis B virus infection in pregnant

women at their first prenatal visit.

Technically a new, requirement, but good

practitioners would already be performing

this function during exams for high risk

individuals.

Hepatitis C virus infection

screening: adults

Screening for Hepatitis C virus (HCV) infection in

persons at high risk for infection. The USPSTF also

recommends offering one-time screening for HCV

infection to adults born between 1945 and 1965.

Technically a new requirement, but

practitioners would already be performing this

function during exams for high risk individuals.

HIV screening: non-pregnant

adolescents and adults

Clinicians screen for HIV infection in adolescents and

adults ages 15 to 65 years. Younger adolescents and

older adults who are at increased risk should also be

screened.

Technically a new requirement, but

practitioners would already be performing this

function during exams for high risk individuals.

HIV screening:

pregnant women

Clinicians screen all pregnant women for HIV, including

those who present in labor who are untested and

whose HIV status is unknown.

Technically a new requirement, but

practitioners would already be performing this

function during exams for high risk individuals.

Intimate partner violence

screening: women of

childbearing age

Clinicians screen women of childbearing age for

intimate partner violence, such as domestic violence,

and provide or refer women who screen positive to

intervention services. This recommendation applies to

women who do not have signs or symptoms of abuse.

Technically a new requirement, but

practitioners would already be performing

this function during exams for high risk

individuals.

Obesity screening and

counseling: adults

Screening all adults for obesity. Clinicians should offer or

refer patients with a body mass index of 30 kg/m

higher to intensive, multicomponent behavioral

interventions.

Covered – already in managed care coverage

requirements. May be performed by a

physician, dietician, or other qualifying

practitioner

Osteoporosis screening:

women

Screening for osteoporosis in women age 65 years and

older and in younger women whose fracture risk is

equal to or greater than that of a 65-year-old white

woman who has no additional risk factors.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Rh incompatibility screening:

first pregnancy visit

Rh (D) blood typing and antibody testing for all

pregnant women during their first visit for

pregnancy-related care.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Rh incompatibility screening:

24–28 weeks' gestation

Repeated Rh (D) antibody testing for all unsensitized

Rh (D)- negative women at 24 to 28 weeks' gestation,

unless the biological father is known to be Rh

(D)-negative.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

STI counseling

High-intensity behavioral counseling to prevent STIs in all

sexually active adolescents and for adults at increased

risk for STIs.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient State Plan service.

Section 13: Alternative Benefit

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

319 | P a g e

Service

USPSTF Recommendations

Application to Medicaid

Skin cancer behavioral

counseling

Counseling children, adolescents, and young adults ages

10 to 24 years who have fair skin about minimizing their

exposure to ultraviolet radiation to reduce risk for skin

cancer.

Broader requirement than currently exists as a

standard Medicaid recipient service.

Tobacco use counseling and

interventions: non-pregnant

adults

Clinicians ask all adults about tobacco use and provide

tobacco cessation interventions for those who use

tobacco products.

Broader requirement than currently exists as a

standard Medicaid recipient service.

Tobacco use counseling:

pregnant women

Clinicians ask all pregnant women about tobacco use

and provide augmented, pregnancy-tailored counseling

to those who smoke.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient service.

Syphilis screening:

non-pregnant persons

Clinicians screen persons at increased risk for syphilis

infection.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient service.

Syphilis screening: pregnant

women

Clinicians screen all pregnant women for syphilis

infection.

Covered – already in managed care coverage

requirements or as a standard Medicaid

recipient service.

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320 | P a g e

13.4.2. Alternative Benefit Plan-Exempt Medically Frail Conditions List

Alternative Benefit Plan-Exempt Medically Frail Conditions List

Effective January 1, 2014; Revised August 15, 2014

In order for a COE 100 (Other Adult Group) Medicaid recipient to be exempt from the Alternative Benefit

Plan (ABP), he/she must have a documented medical diagnosis of one of the conditions or services listed

below.

• Acquired Immune Deficiency Syndrome (AIDS)

• ALS (Lou Gehrig’s Disease)

• Angina Pectoris

• Arteriosclerosis Obliterans

• Artificial Heart Valve

• Ascites

• Blindness

• Cancer (current diagnosis/treatment, within five years)

• Cardiomyopathy

• Chronic Substance Use Disorder – refer to the Substance Use Disorder (SUD) Criteria effective

August 2015 (or subsequent replacement version)

• Cirrhosis of the liver

• Compromised immune system

• Coronary insufficiency

• Coronary occlusion

• Crohn’s disease

• Cystic Fibrosis

• Dermatomayositis

• Diabetes (Insulin Dependent)

• Disability: A physical, intellectual or developmental disability that significantly impairs the ability to

perform one or more ADLs – refer to the NF LOC Supplement effective January 1, 2014 (or

subsequent replacement version)

• Friedreich’s Disease

• Hemophilia

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• Hepatitis C (Active)

• HIV+

• Hodgkin’s Disease

• Huntington’s Chorea

• Hydrocephalus

• Intermittent Claudication

• Juvenile Diabetes

• Kidney failure

• Lead poisoning with cerebral involvement

• Leukemia

• Lupus Erythematosus Disseminate

• Malignant tumor (If treated/occurred within previous five years)

• Metastatic cancer

• Motor or sensory aphasia

• Multiple or Disseminated Sclerosis

• Muscular Atrophy or Dystrophy

• Myasthenia Gravis

• Myotonia

• Open heart surgery

• Organ transplant

• Paraplegia or Quadriplegia

• Parkinson’s Disease

• Peripheral Arteriosclerosis (If treated within previous three years)

• Polyarthritis (Periarteritis Nodosa)

• Polycystic kidney

• Posterolateral Sclerosis

• Renal failure

• Serious Mental Illness – refer to the Serious Mental Illness (SMI) Criteria Checklist effective July 27,

2010 (or subsequent replacement version)

• Sickle Cell Anemia

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• Silicosis

• Splenic Anemia (True Banti’s Syndrome)

• Still’s Disease

• Stroke (CVA)

• Syringomyelia

• Tabes Dorsalis (Locomotor Ataxia)

• Terminal illness requiring hospice care

• Thalassemia (Cooley’s or Mediterranean Anemia)

• Topectomy and Lobotomy

• Wilson’s Disease

Section 13: Alternative Benefit

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13.4.3. Chronic SUD Criteria Checklist

Sources: SMI Criteria 8_19_2015 approved by the Collaborative document, SED Criteria 8_19_2015

approved by the Collaborative document, and Desk Reference to the Diagnostic Criteria from DSM-5.

HSD - March 2016.

SUD Criteria

DSM-V

ICD-9

DSM-V

ICD-10

Description

Substance-Related and Addictive Disorders

292.9

F12.99

Unspecified Cannabis Abuse Disorder

Substance-Related and Addictive Disorders

303.90

F10.20

Alcohol Use Disorder – Moderate, Severe

Substance-Related and Addictive Disorders

304.00

F11.20

Opioid-Related Disorders – Moderate, Severe

Substance-Related and Addictive Disorders

304.20

F14.20

Stimulant-Related Disorder - Cocaine

Substance-Related and Addictive Disorders

304.30

F12.20

Cannabis- Related Disorder - Moderate, Severe

Substance-Related and Addictive Disorders

304.40

F15.20

Stimulant-Related Disorder – Other or unspecified

stimulant

Substance-Related and Addictive Disorders

304.40

F15.20

Stimulant-Related Disorder –

Amphetamine-type substance

Substance-Related and Addictive Disorders

304.50

F16.20

Hallucinogen-Related Disorder- Other

Hallucinogen Use

Substance-Related and Addictive Disorders

304.60

F16.20

Hallucinogen-Related Disorder – Phencyclidine Use

Disorder –

Substance-Related and Addictive Disorders

304.90

F19.20

Other (or Unknown) Substance-Related and

Addictive Disorders

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13.4.4. SMI Criteria Checklist

Serious Mental Illness (SMI) determination is based on the age of the individual, functional impairment, duration of

the disorder and the diagnosis. Adults must meet all of the following four criteria:

□ 1. Age: Must be an adult 18 years of age or older.

□ 2. Diagnoses: Have one of the diagnoses as defined under the current American

Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. The

diagnosis would need to have been determined within the prior 12 months by an

appropriately credentialed and licensed professional.

• Diagnoses codes and descriptions that are found in

Appendix A and Appendix B of this document are those

providing a primary reason for receiving public system BH

services.

□ 3. Functional Impairment: The disturbance is excessive and causes clinically significant

distress or impairment in social, occupational, or other important areas of

functioning.

□ 4. Duration:

□ The disability must be expected to persist for six months or longer.

Person must meet SMI criteria and at least one of the following in A or B:

□ A. Symptom Severity and Other Risk Factors

□ Significant current danger to self or others or presence of active symptoms

of a SMI.

□ Three or more emergency room visits or at least one

psychiatric hospitalization within the last year.

□ Individuals with substance use disorder that complicates SMI and results in

worsened intoxicated/withdrawal complications, bio medical conditions,

emotional/behavior/cognitive conditions.

□ Person is experiencing trauma symptoms related to sexual assault,

domestic violence or other

traumatic event.

□ B. Co- Occurring Disorders

□ Substance Use Disorder (SUD) diagnosis and

any mental illness that affects functionality.

□ SMI or SUD and potentially life-threatening chronic

medical condition (e.g., diabetes, HIV/AIDS, hepatitis).

□ SMI or SUD and Developmental Disability.

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13.4.5. SMI-SED Criteria

SMI-SED Category

DSM-V

ICD-9

DSM-V

ICD-10

Description

Neurodevelopmental Disorders

299.00

F84.0

Autism Spectrum Disorder

Neurodevelopmental Disorders

307.22

F95.1

Motor Disorder – persistent (chronic) motor or vocal tic

Neurodevelopmental Disorders

307.23

F95.2

Tourette’s Disorder

Neurodevelopmental Disorders

307.3

F98.4

Stereotypic Movement Disorder

Neurodevelopmental Disorders

314.00

F90.0

Attention Deficit/Hyperactivity Disorder (ADHD): Predominantly

Neurodevelopmental Disorders

314.01

F90.1

ADHD: Predominantly

Neurodevelopmental Disorders

314.01

F90.2

ADHD: Combined

Neurodevelopmental Disorders

314.01

F90.8

ADHD: Other Specified

Neurodevelopmental Disorders

314.01

F90.0

ADHD: Unidentified

Schizophrenia Spectrum and other Psychotic Disorders

293.81

F06.2

With delusions

Schizophrenia Spectrum and other Psychotic Disorders

293.82

F06.0

With hallucinations

Schizophrenia Spectrum and other Psychotic Disorders

295.40

F20.81

Schizophreniform Disorder

Schizophrenia Spectrum and other Psychotic Disorders

295.70

F25.0

Bipolar type

Schizophrenia Spectrum and other Psychotic Disorders

295.70

F25.1

Depressive type

Schizophrenia Spectrum and other Psychotic Disorders

295.90

F20.9

Schizophrenia

Schizophrenia Spectrum and other Psychotic Disorders

297.1

F22

Delusional Disorder

Schizophrenia Spectrum and other Psychotic Disorders

298.8

F28

Other Specified Schizophrenia Spectrum and Other Psychotic

Schizophrenia Spectrum and other Psychotic Disorders

293.89

F06.01

Catatonia Associated with Another Mental Disorder

Schizophrenia Spectrum and other Psychotic Disorders

298.9

F29

Unspecified Schizophrenia Spectrum and Other Psychotic

Schizophrenia Spectrum and other Psychotic Disorders

301.22

F21

Schizotypal (Personality) Disorder

Bipolar and Related Disorders

293.83

F06.33

Bipolar and Related Disorders due to another medical condition.

Specify.

Bipolar and Related Disorders

293.83

F06.34

Bipolar and Related Disorders due to another medical

Bipolar and Related Disorders

296.40

F31.9

Unspecified

Bipolar and Related Disorders

296.41

F31.11

Mild

Bipolar and Related Disorders

296.42

F31.12

Moderate

Bipolar and Related Disorders

296.43

F31.13

Severe

Bipolar and Related Disorders

296.44

F31.2

With psychotic features

Bipolar and Related Disorders

296.45

F31.73

In partial remission

Bipolar and Related Disorders

296.46

F31.74

In full remission

Bipolar and Related Disorders

296.50

F31.9

Unspecified

Bipolar and Related Disorders

296.51

F31.31

Mild

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SMI-SED Category

DSM-V

ICD-9

DSM-V

ICD-10

Description

Bipolar and Related Disorders

296.52

F31.32

Moderate

Bipolar and Related Disorders

296.53

F31.4

Severe

Bipolar and Related Disorders

296.54

F31.5

With psychotic features

Bipolar and Related Disorders

296.55

F31.75

In partial remission

Bipolar and Related Disorders

296.56

F31.76

In full remission

Bipolar and Related Disorders

296.89

F31.81

Bipolar II Disorder

Bipolar and Related Disorders

296.80

F31.9

Unspecified Bipolar and related disorder

Depressive Disorders

296.99

F34.8

Disruptive Mood Dysregulation Disorder

Depressive Disorders

293.83

F06.31

Bipolar and Related Disorders due to another medical condition

Depressive Disorders

293.83

F06.32

Bipolar and Related Disorders due to another medical condition

Depressive Disorders

293.83

F06.34

Bipolar and Related Disorders due to another medical condition

Depressive Disorders

296.20

F32.9

Unspecified

Depressive Disorders

296.21

F32.0

Mild

Depressive Disorders

296.22

F32.1

Moderate

Depressive Disorders

296.23

F32.2

Severe

Depressive Disorders

296.24

F32.3

With psychotic features

Depressive Disorders

296.25

F32.4

In partial remission

Depressive Disorders

296.26

F32.5

In full remission

Depressive Disorders

296.30

F33.9

Unspecified

Depressive Disorders

296.31

F33.0

Mild

Depressive Disorders

296.32

F33.1

Moderate

Depressive Disorders

296.33

F33.2

Severe

Depressive Disorders

296.34

F33.3

With psychotic features

Depressive Disorders

296.35

F33.41

In partial remission

Depressive Disorders

296.36

F33.42

In full remission

Depressive Disorders

300.4

F34.1

Persistent Depressive Disorder

Depressive Disorders

311

F32.8

Other Specified Depressive Disorder

Depressive Disorders

311

F32.9

Unspecified Depressive Disorder

Depressive Disorders

625.4

N94.3

Premenstrual Dysphoric Disorder

Anxiety Disorders

293.84

F06.4

Anxiety Disorder due to another medical condition

Anxiety Disorders

300.00

F41.9

Unspecified Anxiety Disorder

Anxiety Disorders

300.01

F41.0

Panic Disorder

Anxiety Disorders

300.02

F41.1

Generalized Anxiety Disorder

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SMI-SED Category

DSM-V

ICD-9

DSM-V

ICD-10

Description

Anxiety Disorders

300.09

F43.9

Other Specified Anxiety Disorder

Anxiety Disorders

300.22

F40.00

Agoraphobia

Anxiety Disorders

300.23

F40.10

Social Anxiety Disorder (Social Phobia)

Anxiety Disorders

309.21

F93.0

Separation Anxiety Disorder

Obsessive-Compulsive Related Disorders

294.8

F06.8

Obsessive-Compulsive Disorder due to another medical

condition

Obsessive-Compulsive Related Disorders

300.3

F42

Obsessive-Compulsive Disorder, Hoarding Disorder, Other

Specified Obsessive-Compulsive

Obsessive-Compulsive Related Disorders

300.7

F45.22

Body Dysmorphic Disorder

Obsessive-Compulsive Related Disorders

312.39

F63.3

Trichotillomania (Hair-Pulling Disorder)

Obsessive-Compulsive Related Disorders

698.4

L98.1

Excoriation (Skin-Picking) Disorder

Trauma-and Stressor Related Disorders

308.3

F43.0

Acute Stress Disorder

Trauma-and Stressor Related Disorders

309.0

F43.21

With depressed mood

Trauma-and Stressor Related Disorders

309.24

F43.22

With anxiety

Trauma-and Stressor Related Disorders

309.28

F43.23

With anxiety and depressed mood

Trauma-and Stressor Related Disorders

309.3

F43.24

With disturbance of conduct

Trauma-and Stressor Related Disorders

309.4

F43.25

With mixed disturbance of emotions

Trauma-and Stressor Related Disorders

309.81

F43.10

Posttraumatic Stress Disorder

Trauma-and Stressor Related Disorders

309.89

F43.8

Other specified trauma and stressor-related

Trauma-and Stressor Related Disorders

309.9

F43.9

Unspecified trauma and stressor-related

Trauma-and Stressor Related Disorders

313.89

F94.1

Trauma and stressor-related Disorder

Trauma-and Stressor Related Disorders

313.89

F94.2

Disinhibited Social Engagement Disorder

Dissociative Disorders

300.12

F44.0

Dissociative Amnesia

Dissociative Disorders

300.13

F44.1

With dissociative fugue

Dissociative Disorders

300.14

F44.81

Dissociative Identity Disorder

Dissociative Disorders

300.15

F44.89

Other Specified Dissociative Disorder

Dissociative Disorders

300.15

F44.9

Unspecified Dissociative Disorder

Dissociative Disorders

300.6

F48.1

Depersonalization/Derealization Disorder

Somatic Symptom and Related Disorders

300.11

F44.4

Conversation Disorder (Functional Neurological Symptom

Disorder. Specify: with weakness or paralysis; or with abnormal

movement; or with swallowing symptoms

Somatic Symptom and Related Disorders

300.11

F44.5

Conversation Disorder (Functional Neurological

Symptom) Disorder. Specify: With attacks of seizures; or with

special sensory

Somatic Symptom and Related Disorders

300.11

F44.6

Conversation Disorder (Functional Neurological Symptom)

Somatic Symptom and Related Disorders

300.11

F44.7

Conversation Disorder (Functional Neurological Symptom)

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SMI-SED Category

DSM-V

ICD-9

DSM-V

ICD-10

Description

Somatic Symptom and Related Disorders

300.19

F68.10

Factitious Disorder Imposed on Self, Factitious Disorder Imposed

Somatic Symptom and Related Disorders

300.7

F45.21

Illness Anxiety Disorder

Somatic Symptom and Related Disorders

300.82

F45.1

Somatic Symptom Disorder

Somatic Symptom and Related Disorders

300.89

F45.8

Other Specified Somatic Symptom and

Feeding and Eating Disorders

307.1

F50.01

Anorexia Nervosa – Restricting type

Feeding and Eating Disorders

307.1

F50.02

Anorexia Nervosa – Binge-eating/Purging

Feeding and Eating Disorders

307.50

F50.9

Unspecified Feeding and Eating Disorders

Feeding and Eating Disorders

307.51

F50.2

F50.8

Bulimia Nervosa (F50.2)

Binge-eating Disorder (F50.)

Feeding and Eating Disorders

307.52

F98.3

In children

Feeding and Eating Disorders

307.52

F50.8

In adults

Disruptive, Impulse Control and Conduct

312.33

F63.1

Pyromania

Disruptive, Impulse Control and Conduct

312.34

F63.81

Intermittent Explosive Disorder

Disruptive, Impulse Control and Conduct

312.81

F91.1

Childhood-onset type

Disruptive, Impulse Control and Conduct

312.89

F91.8

Other Specified Disruptive Impulse

Disruptive, Impulse Control and Conduct

312.9

F91.9

Unspecified Disruptive, Impulse Control

Disruptive, Impulse Control and Conduct

Disorders

313.81

F91.3

Oppositional Defiant Disorder –

Specify current severity: Mild

Cyclothymic Disorder

301.13

F34.0

Cyclothymic Disorder

Persistent Depressive Disorder

300.4

F34.1

Persistent Depressive Disorder - Dysthymia

Personality Disorders [For which there is an evidence

based clinical intervention available]

301.83

F60.3

Borderline Personality Disorder

Substance-Related and Addictive Disorders

292.9

F12.99

Unspecified Cannabis Abuse Disorder

Substance-Related and Addictive Disorders

303.90

F10.20

Alcohol Use Disorder – Moderate, Severe

Substance-Related and Addictive Disorders

304.00

F11.20

Opioid-Related Disorders – Moderate

Substance-Related and Addictive Disorders

304.20

F14.20

Stimulant-Related Disorder - Cocaine

Substance-Related and Addictive Disorders

304.30

F12.20

Cannabis- Related Disorder - Moderate

Substance-Related and Addictive Disorders

304.40

F15.20

Stimulant-Related Disorder – Other or

Substance-Related and Addictive Disorders

304.40

F15.20

Stimulant-Related Disorder – Amphetamine

Substance-Related and Addictive Disorders

304.50

F16.20

Hallucinogen-Related Disorder – Other Hallucinogen Use

Substance-Related and Addictive Disorders

304.60

F16.20

Hallucinogen-Related Disorder – Phencyclidine Use Disorder –

Substance-Related and Addictive Disorders

304.90

F19.20

Other (or Unknown) Substance-Related and Addictive Disorders

– moderate, severe

Sources: SMI Criteria 8_19_2015 approved by the Collaborative document, SED Criteria 8_19_2015 approved by

the Collaborative document, and Desk Reference to the Diagnostic Criteria from DSM-5.

Section 14: School-Based Health

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Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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14. School-Based Health Centers

14.1. General Information

SBHCs are a vital part of the health care delivery system in New Mexico. SBHCs are comprehensive

primary health care centers on or adjacent to school grounds that provide PH and BH services to

students and community members. SBHCs also promote positive health behaviors and health care

literacy by increasing health knowledge and decision-making skills in the students they serve. By offering

a range of health care services in school settings, SBHCs simultaneously increase access to care and

decrease the amount of classroom time missed by students leaving campus for care in traditional

settings. As a result, SBHCs can positively impact academic participation as well as health outcomes.

The HSD/MAD supports SBHCs by providing Medicaid reimbursement through MCOs, to SBHCs and their

medical providers for Medicaid eligible members as appropriate. A working partnership between the

New Mexico Department of Health’s Office of School and Adolescent Health (DOH/OSAH) and HSD/MAD

certify that SBHCs meet State quality standards. HSD/MAD contracts with DOH/OSAH for the provision

of funding, leadership, support and oversight to SBHCs across New Mexico. SBHCs may choose to

contract for those provisions through the New Mexico DOH/OSAH.

This policy uses the following terms which take on a unique application to the SBHC program.

Sponsorship - SBHCs contracting with DOH/OSAH do so under either medical sponsorship (i.e., an FQHC

or medical group) or non-medical sponsorship (i.e., an educational cooperative). A Sponsoring Entity

provides its designated SBHC(s) one or more of the following: funding, staffing, medical oversight,

liability insurance, and billing support; and

SBHC Provider Type - SBHCs may apply for approval for HSD/MAD Certification for Medicaid billing as

either a Provider Type 321 (SBHC) or Provider Type 313 (FQHC):

• Provider Type 313 – FQHC:

o An FQHC that meets the definition of a SBHC according to Social Security Act Section 2110 (c) (9)

and is certified by CMS as a FQHC, meets State requirements of an eligible SBHC provider

according to NMAC 8.302.1.10; and

o FQHC Sponsored SBHCs may also contract with the DOH/OSAH for the provision of funding,

leadership, support and oversight.

• Provider Type 321 – Independent/Non-Medical Entity Sponsored:

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o This type of SBHC must contract with DOH/OSAH for the provision of funding, leadership,

support, and oversight.

o SBHCs operating under provider type 321 must do so in collaboration with DOH/OSAH and

HSD/MAD. Although the facilities are not licensed as required by the Medicaid General Provider

Policy (NMAC 8.302.1.10) to meet the definition of an “eligible provider,” the sites participate

under a limited scope of services they are also subject to the New Mexico Standards and

Benchmarks for SBHCs and must pass a periodic on-site review conducted by DOH/OSAH.

If a SBHC sponsored by an FQHC is enrolled as a different provider type than an FQHC, the MCO

shall reimburse according to the SBHC provider type.

SBHC Liaison: By January 1

of each year the MCO will provide an update to HSD with the name of their

designated SBHC Liaison. The SBHC Liaison is the primary contact and will ensure the following:

• Participate in quarterly MCO SBHC Advisory Committee meetings;

• Conduct SBHC recertification site reviews for medically sponsored SBHCs;

• Receive, facilitate, respond and/or provide referrals to subject matter experts within the

MCO for SBHC education, inquiries and general communications with SBHC

stakeholders; and

• Collaborate with HSD/MAD, DOH/OSAH, contractors, SBHC Sponsors and Site

Coordinators.

DOH/OSAH and HSD/MAD will work collaboratively on program planning, policy development,

interagency coordination, and education related to health care services, including primary care, BH, and

dental services, provided by the SBHC and other SBHC programs.

Section 14: School-Based Health

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Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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14.2. Initial Certification Process

SBHCs and sponsoring entities interested in becoming certified for the first time must contact

DOH/OSAH to begin the contracting process. To complete an initial onsite review and receive a MAD

Provider Medicaid Eligibility Letter DOH/OSAH will provide interested parties with the following:

• Standards and Benchmarks;

• SBHC Site Review Self-Assessment; and

• Technical assistance as needed

Any SBHC site that experiences a lapse in eligibility, validation or is an additional SBHC to the Sponsoring

Entity is subject to the same process.

• Initial On-Site Review:

o DOH/OSAH will conduct an initial on-site review with the SBHC staff and sponsor to include

discussion of findings, questions, concerns, and recommendations;

• DOH/OSAH will provide HSD/MAD with documentation of the initial on-site review

o HSD/MAD will issue a letter to the SBHCs, sponsor, DOH/OSAH, and the MCOs within 10 to 15

business days after completion of site review indicating whether the SBHC has passed or failed

the review:

• If the SBHC/Sponsor passed, the HSD/MAD letter will include the effective date the SBHC

and Sponsor are eligible to begin billing Medicaid; and

• If the SBHC/Sponsor failed, the HSD/MAD letter will include the reasons and requirements

the SBHC must complete to pass the certification/recertification process. If the

SBHC/Sponsor is not able to correct the noted deficiencies within 10 business days from

receipt of letter, HSD/MAD will send notification to the SBHC/Sponsor requesting a

corrective action plan (CAP).

• The CAP must address each noted deficiency, action steps required to correct the

deficiency, and the desired outcome with a due date;

• The SBHC/Sponsor will have 60 calendar days upon receipt of the notification to

implement the CAP and correct all deficiencies. Evidence of the corrections must be

submitted to HSD/MAD before or on the 60th calendar day;

• HSD/MAD will determine what documentation and in what format is required based on

the CAP and resolution of deficiencies;

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• HSD/MAD will send a letter of certification/recertification to the SBHC, sponsor,

DOH/OSAH, and the MCOs within five business days of resolution of deficiencies and

completion of the CAP; and

If the CAP is not completed and deficiencies are not resolved, HSD/MAD will collaborate with

DOH/OSAH to determine if certification/recertification is possible and next steps.

• Centennial Care Enrollment:

o SBHCs must obtain an individual NPI from CMS.

o SBHCs must submit a MAD 335 application to Conduent as either provider type 313 or provider

type 321:

• SBHCs with Provider Type 313 must submit a copy of documentation from CMS certifying

the center as an FQHC; and

• SBHCs with Provider Type 321 must submit a copy of the MAD Medicaid Eligibility Letter.

o Upon completion of the successful enrollment with HSD/MAD, SBHCs will finalize agreements

with MCOs:

• SBHCs will also affiliate every rendering provider with the SBHC in the New Mexico Medicaid

System;

• It is the SBHC’s responsibility to contact each MCO; and

• MCOs are required to make best efforts to contract with SBHCs per Section subsection

4.8.13.1 of the Agreement.

14.3. Recertification Process

The HSD/MAD letter of New Mexico Medicaid Eligibility is issued for a period of three years and is

subject to revocation in the event that HSD/MAD becomes aware of loss of appropriate licensure(s) or

significant deviation from the Standards and Benchmarks. Recertification must be conducted prior to

the expiration of the initial certification and every three years after.

• Provider Type 321s with Non-Medical Sponsorship Recertification Process review will be conducted

by the DOH/OSAH Site Review Team no later than six weeks before the expiration of current

certification.

o DOH/OSAH will schedule the site review through the SBHC’s Sponsoring Entity.

Section 14: School-Based Health

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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o DOH/OSAH shall ensure the Sponsoring Entity has access to the most recent copy of the

Standards and Benchmarks, SBHC Site Review Self-Assessment, and the Site Review Guide

within one month of the site review.

o The DOH/OSAH site review will be conducted as outlined in Certification Process above.

• The recertification process for Medically Sponsored SBHCs contracted with DOH/OSAH is the

responsibility of the MCOs.

o In January of each year, no later than the first quarterly meeting of the MCO SBHC Advisory

Committee, HSD/MAD will provide the MCOs with a list of medically sponsored DOH/OSAH

contracted SBHCs with expiring certifications, including recertification due dates, and the MCO

responsible for performing the on-site review.

o The MCO will schedule the on-site review with the Medical Sponsor for no later than six weeks

before the expiration of current certification.

o The review may be conducted remotely for additional SBHC sites. There is no requirement for an

on-site visit for every individual SBHC under the same sponsoring entity.

o In preparation of the on-site review the MCO shall:

▪ Within one month of the site review ensure the Medical Sponsor has access to the most

recent copy of the Standards and Benchmarks, SBHC Site Review Self-Assessment, and the

Site Review Guide.

▪ Instruct the Medical Sponsor and SBHC to prepare to make available hard or electronic

copies of:

• Attestation Statement for Federally Qualified Health Centers (Exhibit 177) or copy of

Acknowledgment of Ability to Comply with New Mexico Standards and Benchmarks

for School-based Health Centers.

• Facility Documentation:

o Facility licenses,

o Evidence of other licensure and/or certification by appropriate jurisdictional

agencies as requested;

o The latest fire inspection report by the fire authority with jurisdiction over the

site;

o Valid license from the New Mexico Board of Pharmacy;

o Current Clinical Laboratory Improvement Amendments (CLIA) certificate;

Section 14: School-Based Health

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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o Evidence of compliance with such standards such as the requirement for “No

Smoking” signs, “Handicap Accessibility” signs, and the posting of appropriate

licenses

• SBHC Policy and Procedure Manual, including the policies and procedures described

in the Standards and Benchmarks;

• Complaint logs, Material Safety Data Sheets (MSDS), pharmacy logs, and laboratory

logs;

• Access to Medical Records;

• Other materials that may be specified by the Site Review Team;

• Staff Documentation:

o Current license, registration or certificate of each staff member for which a

license, registration, or certification is required by the State of New Mexico;

o Health training certificates and logs of all staff;

• Completed SBHC Site Review Self-Assessment for every SBHC;

o Review the completed SBHC Site Review Self-Assessment for completeness and

discrepancies;

o MCO’s should reschedule the onsite review if SBHC Site Review Self-Assessment

is not provided 1 week prior or is incomplete;

o Recertification Onsite Review shall:

▪ Meet with the clinic staff and sponsor representatives in person, to discuss the site review

process;

▪ Conduct a visual review and use the HSD/MAD Electronic Assessment Tool to determine

adherence to the SBHC Standards and Benchmarks;

▪ Medical Record Review of the designated MCOs members shall be conducted per the

HSD/MAD training guidelines; and

▪ Conduct an exit interview with the staff and sponsor to discuss findings, questions,

concerns, and recommendations. Sponsor will sign the Electronic Assessment Tool

Summary and a verbal indication will be given of the certification status.

o After Onsite Review Activities:

▪ The MCO will deliver the site review documentation to HSD/MAD within 10

business days. This documentation includes:

Section 14: School-Based Health

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o All SBHC Site Review Self-Assessment(s)

o Electronic Assessment Tool- Scoring

o Electronic Assessment Tool- Summary

▪ HSD/MAD will compile the data and make the final determination for

recertification. HSD final determination will be demonstrated by the MAD

Medicaid Eligibility Letter. This letter will be distributed by HSD/MAD directly to

the Sponsoring Entity and MCOs.

▪ If the SBHC/Sponsor failed, HSD/MAD will follow the CAP process as outlined in

the initial certification section.

14.4. Adolescent Confidential Services and Suppression of Explanation of Benefits (EOBs)

SBHC services are subject to Federal and New Mexico state law. There are a number of circumstances in

which an adolescent (an un-emancipated minor) may consent to receive services without parental

consent, including the following:

• Treatment for Sexually Transmitted Diseases:

Under Section 24-1-9 (capacity to consent to examination and treatment for a sexually transmitted

disease), any person regardless of age has the capacity to consent to an examination and treatment

by a licensed physician for any sexually transmitted disease; however, under Section 24-1-9.4,

disclosure of the test results is authorized “to the subject of the test or the subject’s legally AR,

guardian or legal custodian.”

• Pregnancy Examination and Diagnosis:

Under Section 24-1-13 (pregnancy; capacity to consent to examination and diagnosis), any person,

regardless of age, has the capacity to consent to an examination by a licensed physician for

pregnancy.

• Family Planning Services:

Under Section 24-8-5 (prohibition against imposition of standards and requirements as prerequisites

for receipt of requested family planning services) there are no prerequisites for parental consent to

obtain family planning services.

• BH Services:

Section 14: School-Based Health

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January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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Under Section 32A-6-14 (treatment and habilitation of children; liability), parental consent is not

required to receive “individual psychotherapy, group psychotherapy, guidance, counseling or other

forms of verbal therapy that do not include any aversive stimuli or substantial deprivations.”

MCO contracts require the MCOs to adopt and implement written confidentiality policies and

procedures that conform to state and Federal laws and regulations that:

o Preserve adolescent members’ confidentiality rights; and

o Honor adolescent members’ rights to receive confidential services under HIPAA and other State

and Federal confidentiality provisions.

MCOs are required to adopt and implement policies and procedures unique to SBHCs beyond State and

Federal laws and regulations that:

• Suspend the distribution of EOBs and any other communication, written or electronic, to the

guardian for all confidential services provided at SBHCs. This would include lab and test results,

patient satisfaction surveys, patient portal records, and any other communication that would

result in a breach of confidentiality related to adolescent confidential services.

Section 15: I/T/U

Revision dates: August 15, 2014; March 3, 2015

Effective dates: January 1, 2014

337 | P a g e

15. Indian Health Services, Tribal Health Providers, and Urban Indian Providers (I/T/U)

15.1. FQHC/Tribal 638 Claims Processing (Alamo and Pine Hill)

MCOs must configure their systems to pay claims either off of the COBA (Coordination of Benefits

Agreement) file or paper claims and pay up to the Medicare OMB rate for the applicable year.

For IHS and Tribal 638 facilities when there is a Medicare reimbursement for services that are not

included in the OMB rate, for services billed on a UB claim form (used by hospitals and facilities),

Medicaid pays the co-insurance and deductible calculated by Medicare regardless of the revenue code

billed. These Medicare crossover claims may also include specific services such as rehabilitation services,

flu shots, and supplies. After Medicare payment is made, reimburse the Indian Health Services and

Tribal 638 facilities for the full co-insurance and deductible calculated by Medicare regardless of the

service or revenue code used.

For services provided to recipients with primary medical coverage by a third party, such as an insurer or

other third party (excluding Medicare) who may be liable for the medical bill, Medicaid reimbursed the

provider the Medicaid Inpatient or Outpatient OMB rate for that calendar year less the third-party

payment.

Services must be delivered in locations identified in Medicaid policy or locations consistent with

professional standards of practice. Services locations outside the IHS or Tribal 638 facilities may include

locations such as NFs, schools, teen and wellness centers, chapter houses, homes, and non-IHS/Tribal

638 hospitals.

Section 16: Fair Hearings

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

338 | P a g e

16. Fair Hearings

16.1. Administrative Hearings

Reference: 8.308.15 NMAC Grievances and Appeals

Under managed care rules, the MCO must have a grievance process and an appeal process for members

as described in the above rule. The MCO must be familiar with the provisions of the rule and have

procedures in place that follow the rule.

All rules and requirements related to the appeal and hearing processes must be followed from the initial

adverse determination, which would typically either be the denial or reduction of a requested service or

LOC, or the discontinuation or reduction of an existing service or LOC. However, the right to an appeal

and hearing process is also required when a new decision is made, even if that action is to increase or

extend a benefit and, therefore, may not initially appear to be “adverse.”

The member may still appeal an action that has been taken to increase or extend the same benefit. For

example, if the member receives increased PCS hours, but the hours are less than what the provider

requested or less than what the member feels are needed, the member can still appeal that action; in

the sense that the action is considered an adverse action, if that is how the member perceives it. When

the notice is sent, it should be labeled as the Notice of Action.

Any instance for which an approval, authorization, LOC, frequency, or other amount is not approved to

the extent requested by the provider or member is considered an adverse action and may be referred to

as such.

Time limits requiring advance notice prior to the MCO taking an adverse action against a member’s

existing service or LOC, (including actions by a member’s receiving MCO that did not authorize the

original service) are all important and must be followed. It is from that initial adverse action, and the

adverse action that a receiving MCO may take, that all the remaining provisions of the notification,

rights to continuation of a benefit, MCO appeal, and HSD administrative hearing process may follow.

Therefore, all notices to the member must accurately advise the member of his or her appeal rights, and

all notices must adhere to the time frames specified.

Grievances

The grievance process should not be confused with the appeal and administrative hearing processes.

The appeal process can eventually lead to an HSD administrative hearing before the HSD Fair Hearings

Bureau (FHB). The grievance process is an internal resolution process within the MCO. The MCO must

always make it clear to the member when to file an appeal rather than to file a grievance. A member

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may file an appeal if he or she is unsatisfied with the outcome of the grievance process as long as the

member is still within the time requirement for filing an appeal. However, the appeal is made on the

basis of the Notice of Action and not an appeal on the grievance resolution. Filing a grievance in no way

alters or extends the time that the member has to file an appeal.

Provider Appeal

The provider appeal process is included in the above rule. This process exists only within the member’s

MCO. While HSD does have a provider hearing process for some fee-for-service provider issues, the

MCO provider appeal process does not lead to an HSD administrative hearing before the FHB.

Member Appeal

The member MCO appeal process is included in the above rule. The member MCO appeal process can

eventually lead to an HSD administrative hearing before the FHB.

The MCO must assure that the member is informed of all rights regarding the right to an appeal and the

MCO appeal process, and as applicable, an HSD administrative hearing process. The MCO must follow all

the requirements of the rule related to the MCO appeal process.

In order to consolidate the requirements of state and Federal rules, MAD has developed checklists for

notices and letters contained in the Appendix.

16.2. The Member’s HSD Administrative Hearing

Reference: 8.352.2 NMAC Claimant Hearings

When the member has exhausted his or her MCO appeal process, and if the member acts within the

time frame specified in 8.308.15 NMAC and 8.352.2 NMAC, the member has the right to file a request

for an HSD administrative hearing with the FHB. Within HSD, the terms Administrative Hearing and Fair

Hearing mean the same thing.

Once a member receives an MCO appeal final decision and the member elects to request an HSD

administrative hearing, the member and MCO are governed by the NMAC 8.352.2 rule. The process the

member and MCO are to follow for an HSD administrative hearing is detailed in this rule.

Once a member’s request for an HSD administrative hearing has been received by the FHB, and if the

member was approved for a continuation of his or her benefit during the MCO appeal process, the

member’s continuation of the benefit remains in place until an HSD administrative hearing final decision

is rendered or the member requests the termination of continuation of the benefit.

Section 16: Fair Hearings

Revision dates: August 15, 2014; March 3, 2015;

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Effective dates: January 1, 2014

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Once a member notifies the FHB, the FHB acknowledges receipt of the request to the member and

notifies the MAD Administrative Hearing Unit (AHU) and the MCO in writing of the request within

relevant information about the member, including the member’s self-identified issues. MAD AHU

maintains a log of all HSD administrative hearing requests. Once the FHB assigns an administrative law

judge (ALJ), the ALJ will send out a scheduling notice of the HSD administrative hearing date, time, and

call in number to all parties. Parties to the hearing may include legal counsel or other ARs. Unless an

accommodation is requested and approved by the ALJ, all HSD administrative hearings are conducted

telephonically. The assigned ALJ is responsible for the oversight of the HSD administrative hearing

process, including conducting the actual hearing.

The formal rules of evidence and civil procedure do not apply to the HSD administrative hearing

proceedings. Relevant evidence is submitted into the hearing record and testimony is furnished during

the proceedings in an orderly, but less formal, manner. However, the record created for the HSD

administrative hearing is a legal document and is the record which forms the basis for decisions made by

a New Mexico district court, if the member should see redress after his or her HSD administrative

hearing final decision has been rendered. The evidence and testimony entered into the hearing record

forms the official HSD record and only information contained within the hearing record can be admitted

into evidence in a New Mexico district court appeal; HSD, the member or the MCO cannot add to or

delete from this hearing record after the close of the actual HSD administrative hearing. The State

district court is allowed to set aside the HSD administrative final decision only if it finds the decision to

be arbitrary, capricious or an abuse of discretion, not supported by substantial evidence in the hearing

record as a whole, or otherwise not in accordance with the law.

SOE

The MCO must provide MAD with a SOE within 7 calendar days after receipt of a request, but no later

than 15 business days prior to the initial scheduled hearing. The SOE must contain copies of all

documentation used to make the decision, and it must explain the reasons for the benefit determination

and address all of the member’s concerns.

Within the specified time frames, the MCO must submit an electronic copy of the SOE to the MAD AHU

through the DMZ. The SOE must include relevant NMAC rules, demographic information, summary of

issues, clinical and administrative documentation, correspondence, etc. MAD will be responsible for

completing the member demographic section of the summary.

Section 16: Fair Hearings

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

341 | P a g e

The SOE must refer to all relevant State and Federal statutes, rules, and other criteria used to make the

decision. Upon request and no later than 7 calendar days after receiving the request, the MCO must

provide the member and/or the member’s representative (with written consent of the member) the

member’s case file and provide copies of documents contained therein without charge.

Final Decision

At the conclusion of the HSD administrative hearing, the ALJ prepares a summary of facts and his or her

recommendation and submits this and the entire hearing record to MAD AHU. The record of the HSD

administrative hearing is reviewed by the Director of MAD or his or her designee and the final decision

rests with the Director or his or her designee. Under Federal law, the entire HSD administrative process

must be completed within 90 calendar days of the date the member requested an HSD administrative

hearing. The member and other parties to the hearing are provided with the HSD administrative hearing

final decision.

The member has 30 calendar days to file an appeal of the HSD administrative hearing final decision with

the appropriate New Mexico district court. The filing of a Notice of Appeal shall not stay the

enforcement of the HSD administrative hearing final decision. The member may seek a stay upon a

motion to the court or the member may request the MAD Director or designee to stay the HSD

administrative hearing final decision while the adverse action is on appeal in a New Mexico district

court. If the court orders a stay, the MCO will maintain the benefit at issue in accordance with the State

district court’s order. If the New Mexico district court’s final decision is in favor of HSD and the member

continued utilizing his or her benefit during the district court appeal process, see 8.352.2.19 NMAC for

the repayment process.

Important Aspects of the Process

One of the HSD’s primary goals related to its administrative hearings is to have all MCO’s implement

procedures that are consistent with NMAC and MAD rules and that will be practiced and adhered to by

all parties involved. The following are focus points for process improvement:

• Timeliness in all phases of the process;

• Maintain member confidentiality and protect PHI;

• Emphasize maintenance of complete and organized files;

• Emphasize importance of documentation; and

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• Accountability

The MCOs are key players in this process; therefore, MCO participation to assist with the process is

required. As part of this initiative, and in order to maintain organized and complete files, HSD is

requesting all MCOs use a standardized HSD SOE form. Each SOE shall contain four separate titled

sections. The MCO is to provide the information listed on each titled section of the SOE to MAD AHU in a

timely manner so it may meet HSD administrative hearing and Federal CFR requirements.

Special Situations

There have been questions related to whether both the relinquishing and receiving MCOs are to

respond to their members’ appeals and participate in the HSD administrative hearing when a member is

transitioning from one MCO to another.

Each MCO is responsible for its own process while still following the instructions for continuation of

benefits for the initial 30 calendar days after transfer; the member’s right to request an MCO appeal,

and for a continuation of his or her benefits.

Questions and Answers

• If a member requests an MCO appeal or an HSD administrative hearing for a service that has not

been provided, and it is found they will be transferring to another MCO while the member’s MCO

appeal process or his or her HSD administrative hearing is underway, how should we proceed?

o For a requested benefit that has not been provided:

• The relinquishing MCO must still complete the MCO appeals process even if the appeal

decision or HSD administrative hearing takes place after the member has transferred.

However, if the decision comes after the member has transferred, it may be reasonable for

the MCO’s final appeal decision to be that the member is no longer enrolled in the MCO so

the service cannot be provided through the relinquishing MCO. Even then, the member may

appeal the decision to HSD, but likely the finding would be the same.

• The member needs to file a new request for services with the receiving MCO because that

will be the MCO responsible for providing the service. If the receiving MCO denies the

service, then a new appeal process begins with the receiving MCO.

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Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

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• If a member is still in the MCO when the decision is made, the MCO decision must be based

on the information provided during the MCO appeal process and not denied on the basis

that the member will be transitioning to a new “receiving” MCO soon.

o For an existing benefit which is being provided subject to a continuation of benefit request:

• The relinquishing MCO must still complete the MCO appeals process even if the appeal

decision or HSD administrative hearing takes place after the member has transferred. This is

essential because a final determination must be made to determine if the member is

responsible for payment for services that were “continued” under the relinquishing MCO for

the time period the member was enrolled with the relinquishing MCO.

• When the relinquishing MCO makes a final decision on the member’s appeal, or when the

HSD administrative hearing final decision is rendered, it is applicable only for the time

period that the member was enrolled in the relinquishing MCO.

• Because a receiving MCO issues its own notice of adverse action concerning the same

benefit, the receiving MCO’s appeal process and possible subsequent HSD administrative

hearing is applicable only for the time period that the member is in the receiving MCO.

Therefore, it is possible that there may be concurrent appeals and administrative hearings

for the same member for the same benefit but for different time periods. The different time

periods correspond to the relevant dates that the member was enrolled in each MCO.

• What happens in the case when the receiving MCO does not agree with the relinquishing MCO’s

decision?

o If the relinquishing MCO makes a decision for a benefit for a time period the member is still

enrolled in the relinquishing MCO, the receiving MCO must accept that as the benefit the

member has in place at the time of the transfer to the receiving MCO. The service must initially

be continued through the receiving MCO under the transition of care provisions. The receiving

MCO can notify the member of its intent to take an adverse action against the member’s benefit

provided it is given 10 calendar days prior to ending the service (Notice of Action). See 8.308.11

NMAC Transition of Care for specific services that may allow for other considerations.

o However, the receiving MCO must initially continue to provide the relinquishing MCO’s

approved benefit. The member and the receiving MCO essentially begin the process of notice

and right to appeal again. The receiving MCO must follow the same process with regard to time

and notice. The receiving MCO would notify the member of its intent to take an adverse action

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concerning the member’s existing benefit, LOC, or service within 10 calendar days prior to the

date of the intended adverse action. The member must file a new appeal request with the

receiving MCO. The member has the right to make a new request for a continuation of the

benefit from the receiving MCO and must do so in order for the benefit to continue during an

appeal process. The member’s request for a continuation of benefits to the relinquishing MCO

does not carry over to the receiving MCO. This process must be made clear to the member.

o HSD want to emphasize the contract provision for the 30 calendar day coverage of the

member’s benefit by the receiving MCO is an HSD contract requirement, but it does not replace

the responsibility of the MCO to follow Federal and State laws, statutes, regulations and rules

for member notification when it intends to take an adverse action against the member, the

member’s right to appeal, and the right for continuation of the member’s benefit.

• How will each MCO’s Medical Director fit into the scenario? Are they going to have to work with the

new MCO to handle a re-review if there is a disagreement?

o See the answer above. Each MCO handles the issue separately.

• Will the member need to know this is going on and who would be responsible to let the member

know this is occurring?

o The member does need to be informed. The member is entitled to a notice of adverse action

from the receiving MCO, as he or she received from the relinquishing MCO. The communication

to the member must be clear about the need to file a new MCO appeal request and make a new

request to his or her receiving MCO for a continuation of his or her benefit during the MCO

appeal process.

• Is the current MCO’s decision binding regardless of the other MCO’s opinion?

o The only sense in which it is “binding” is that if a benefit was provided by the relinquishing MCO,

even if that benefit was provided through an appeal or administrative hearing process, that

member is considered to have that benefit at the time of transfer to the receiving MCO. As for

any benefit which the member is receiving when he or she transfers into a receiving MCO, the

receiving MCO must initially provide the benefit, but it is subject to a new notice of adverse

action or re-authorization.

• Will each receiving and relinquishing MCO need to continue to do this process anytime a member

changes MCO?

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o Yes, when a member is transitioning to another MCO, and the receiving MCO is intending to

take an adverse action effecting a benefit against a member (that is, discontinue or reduce the

existing service). The relinquishing and receiving MCOs each make their decisions separately for

the time period that the member is in their MCO; however, the receiving MCO still has the

responsibility for new notification of its intent to take an adverse action against the member.

• How will each MCO’s Appeal Unite be notified when a member has changed MCO?

o The relinquishing MCO would know when the member leaves. Its appeal unit should review the

enrollment status of the members that have an ongoing appeal on a monthly basis.

o The receiving MCO knows when it receives a transitioning new member. When a provider is

rendering an existing benefit approved by the relinquishing MCO, and that benefit requires

authorization or a LOC, a provider may need to report when requesting an authorization to the

receiving MCO that the member has already been receiving the benefit. The notification that

goes to a member upon denying an existing benefit is significantly different from the notice that

denies a new benefit. The receiving MCO’s member services unit may be the first to learn about

this issue by receiving a call from a member. Several receiving MCO units would likely be aware

of its transitioning member’s rights through the relinquishing MCO to request a continuation of

his or her benefit and of the member’s request for a MCO appeal of the adverse action, as well

as which benefits the relinquishing MCO is covering under a continuation of benefits.

Information to Consider Regarding Member Notices and Letters

All MCOs are required to produce a simple, clear notice or letter that includes the mandated

information detailed in the checklists accompanying this Manual section.

It is the MCO’s choice on how to address this issue. Some MCOs have been handling this requirement by

creating multiple distinct letters and notices that include necessary topics but exclude any irrelevant

information. For example, if the issue is the denial of an authorization for a new service, it is not

necessary to include “Continuation of Benefits” information in the letter or in the accompanying packet.

If the adverse action is a benefit that is not currently being provided, there is no need to include

information about Continuation of Benefits in the letter or packet. If the Standard Appeal was made in

writing, there is no need to include information to the member that if the appeal was made verbally, a

written request must be made within 13 calendar days.

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Each checklist allows for some variations in the letters and notices that the MCO must have, but the

MCO is not limited to the variations specified in the checklists. The MCO may have as many letters and

notices as necessary to clearly and effectively communicate to its members.

There must be recognition and use of the standard terms: “Grievance”, “Appeal”, and “HSD

Administrative Hearing”. The MCO may use the term “Formal Complaint” instead of “Grievance”;

however, the letter should clarify that a Formal Complaint is equivalent to the Grievance process, so a

member can relate the terms in the MCO’s notice to the terms used in HSD rules. Notices, letters, forms,

and information on the member’s rights should always be clearly labeled.

A Notice of Action is required when a new decision is made, even if the action is to increase or extend a

benefit. Therefore, MAD uses the term “Notice of Action”, not “Notice of Adverse Action”.

It is important the Notice of Action be clear in distinguishing between what was requested and what was

approved. If everything that was requested is approved, the Notice of Action should state that fact. In

such instances, it would be inappropriate to refer to the action as an adverse benefit determination or

an adverse action.

When the checklist instructs the MCO to provide a “contact” for the member, it does not have to be the

name of a specific individual. The MCO may follow its own process for setting up a contact system.

MCO notices should indicate that a member may request a “quick decision” when the member believes

their health or life is endangered while awaiting a decision. This is an important provision so a member

whose condition has changed or who need immediate attention can be assisted by the MCO.

Additional Aspects of Approvals and Denials Leading to Appeals

It is important the Notice of Action be based on the most complete information available. Therefore,

when considering a LOC or approval of a new item or service, an MCO may ask for additional or

clarifying information from the provider requesting the LOC or service in order to arrive at the most

appropriate decision and avoid an unnecessary appeal.

An MCO is not required to hold any kind of conference or pre-appeal decision discussion with the

requesting provider or the member; however, if the MCO believes this may help resolve the issue, the

MCO may schedule such conferences. Failure on the member’s part to attend such a conference cannot

be used as a reason to dismiss the appeal.

Before an appeal turns into an HSD Administrative Hearing, it is important it be clear what is in dispute

regarding the benefit.

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If the Notice of Action is related to a PASRR determination, the member should not be asked to file an

appeal with the MCO. Instead, the member should file for an Administrative Hearing; the proper

agencies will then become involved in the consideration. If the benefit is already being used, the

Continuation of Benefits is automatic and the member never pays for using the continued benefit.

Important Timelines

• Response to Request for Authorized Service or Other Approval

A decision on a standard authorization request must be issued as expeditiously as the member’s

health condition requires, but no later than 14 calendar days following receipt of the request for

new services, and no later than 10 calendar days following receipt of a request to continue ongoing

services.

Note that the checklist contains information about a “quick decision” even though that term is not

found in rules or contracts. It is important that an MCO be able to assist any member who believes

that their health or life is endangered while awaiting a decision; therefore, a member is allowed to

change a request for a Standard authorization request to an Expedited authorization request at any

time during the appeal process. The member is also able to contact the MCO and express the need

for a “quick decision” so that the MCO is informed of any developing medical issues or conditions

and can react, as necessary, to that situation. An extension of up to 14 calendar days is allowed

when following the HSD MCO contract provisions.

• Notice of Action Letter

A Notice of Action of reduction, increase, or termination of any benefit or LOC or budget amount

must be sent to the member at least 10 calendar days prior to the date the intended action will take

effect. The same timeframe and requirement for a Notice of Action is necessary following a review

or re-determination; when a benefit is extended with no change from the current benefit; or, if a

new benefit is approved as requested.

Special provisions apply for members in NFs. Federal regulations in 42 CFR 483.15 require NFs

provide a 30-day notice to the member in many instances related to a transfer or discharge. There

are exceptions provided. The MCO must be certain the NF has followed Federal requirements and

cannot provide a date for the discharge or transfer of a member in an NF that is earlier than the

date the NF states in their notice to the member. The MCO Notice of Action does not replace the

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need for the NF to comply with the Federal requirement. See: Notice Of Action letter to member

regarding VAS.

• Continuation of Benefits may be established using the following process

The member may request a continuation of a current benefit any time prior to the date the adverse

action goes into effect; or within 10 calendar days of the Notice of Action, whichever is later.

• Appeals

The member has 60 calendar days from the date of the Notice of Action to file an appeal. If the

member appeal is a Standard Appeal and the request is made verbally, the member must submit the

appeal in writing within 13 calendar days of the verbal appeal.

If the member appeal is an Expedited Appeal, a verbal request is sufficient; it does not need to be

followed up in writing.

MCO Acknowledgement of Member Appeals

The MCO acknowledges the Standard Appeal within 5 business days of the receipt of the appeal. It is

important that an MCO be able to assist any member who believes that their health or life is

endangered while awaiting a decision: therefore, a member is allowed to change a request for a

Standard Appeal to a request for an Expedited Appeal.

MCO Member Appeal Final Decision Letter

The MCO provides an appeal decision letter within 30 calendar days of the receipt of the appeal for

a Standard Appeal, or within 72 hours for an Expedited Appeal; unless a notice of the need for an

extension is sent within these same time frames.

The MCO must provide notice to the member within 2 calendar days of any decision to extend the

timeframe necessary to provide a decision. See Letter Informing the Member of a Delay for an

Appeal Decision.

• Grievance

A Grievance may be filed at any time. An MCO cannot change a requested Appeal into a Grievance

without written consent from the member.

Acknowledgement of Receipt of a Member-Filed Grievance

An Acknowledgement of a member grievance must be sent within 5 calendar days of receipt by the

MCO.

Member Grievance Final Letter

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A Resolution of Grievance Letter must be provided within 30 calendar days of the date of receipt of

the grievance or as expeditiously as the member’s health require.

Member Grievance Extension Request

The MCO may request an extension from HSD. For any extension not requested by the member, the

member must be provided a written notice within 2 calendar days of the decision to extend the time

frame.

• HSD Administrative Hearing

The member may request an HSD administrative hearing within 90 calendars days of the MCO

appeal final decision letter. For an Expedited Hearing, the request must be within 30 calendar days.

16.3. Appendices

The following pages contain checklists for specific information that must be contained in the Notice of

Action to a member, and the other letters and notices associated with steps relating to grievances,

appeals, and a final decision letter.

The MCOs are to review their notices and letters, revise them as necessary, and submit them to MAD for

final approval.

16.3.1 MCO Checklist – Acknowledgement of Receipt of a Member-filed Grievance

16.3.2 MCO Checklist for Member Grievance Final Letter

16.3.3 MCO Checklist for Notice of Action Letter to Member

16.3.4 MCO Checklist for Notice of Action Letter to Member Regarding Value-Added Services

16.3.5 MCO Checklist for the Acknowledgements of Member Appeals

16.3.6 MCO Checklist for Letter Informing the Member of a Delay for an Appeal Decision

16.3.7 MCO Checklist for the MCO Member Appeal Final Decision Letter

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16.3.1. MCO Checklist – Acknowledgement of Receipt of a Member-Filed Grievance

MCO Checklist - Acknowledgement of Receipt of a Member-filed Grievance

The Acknowledgement must include:

The date that the Grievance was received.

The MCO’s understanding of the issue.

When the member may expect a resolution or other response to the Grievance, not to exceed 30

calendar days from the receipt of the Grievance.

That the member has the right to present evidence and testimony and make legal and factual

arguments on the issue before the MCO determines the resolution of the Grievance. This

presentation may be made by the member, a spokesperson or any designated or authorized

representative. The member or authorized individual must make a request for this presentation and

the MCO must schedule this presentation prior to making a determination on the Grievance. The

MCO must tell the member of the limited time the member has to make this request in order for the

MCO to provide a resolution within the required timeframe.

If the Grievance is related to a response to a Notice of Action for which there could be a member

Appeal, include the following:

Information on the difference between a member Grievance and an Appeal, including if they want

to file an Appeal they must do so within 60 calendar days of the Notice of Action; and that a

Grievance is not considered an Appeal and does not extend the timeframe in which an Appeal must

be filed.

A member may file a Grievance to express dissatisfaction about any matter or aspect of his or her

MCO’s operation. A member files an Appeal to begin a process for reconsidering an adverse action

as described in a Notice of Action.

Instructions on how to file an MCO member Appeal if the issue is better resolved through an MCO

member Appeal instead of an MCO Grievance.

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A statement the member cannot request an MCO member Appeal on the issue if he or she does not

agree with the final Grievance decision, unless the timeframe for an Appeal following a Notice of

Action is met and the Appeal is based on the Notice of Action, not on the Grievance decision.

A MCO Grievance contact that includes email and mail addresses, fax and telephone numbers.

Include the hours this contact is available, as well as an emergency number. Inform the member to

use this contact information if he or she has any questions. Inform the member how to access

toll-free numbers with TTY/TTD and interpreter ability.

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16.3.2. MCO Checklist for Member Grievance Final Letter

MCO Checklist for Member Grievance Final Letter

The letter should include the following:

The date of the letter, which should be the date the letter will be mailed.

A summary of the Grievance.

If an action was taken or is going to be taken, include a description of the action.

An explanation of why no action will be taken to resolve the issue or why no action is necessary. This

explanation must be based on rules and requirements or established MCO policies and procedures.

A statement that the MCO grievance decision letter ends the MCO member Grievance process.

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16.3.3. MCO Checklist for Notice of Action Letter to Member

MCO Checklist for Notice of Action Letter to Member

The following sections, at a minimum, should be included in the written Notice of Action Letter. There

may be two versions as necessary:

1. Notice regarding an existing benefit;

2. Notice regarding a newly requested benefit;

➢ Notice of Action letter;

➢ Notice of the Right to file a Grievance;

➢ Notice of the Right to request an Appeal

➢ Notice of the Right to file a Grievance and request an MCO Appeal concurrently; and/or

➢ Notice of the Right to a Continuation of Benefits.

Notice of Action should include:

The date of the Notice, which must be the date the Notice will be mailed. If the Notice is to

terminate an existing benefit, the date must not be less than 10 calendar days prior to the date the

benefit will end.

A description of what action the MCO intends to take or has taken to terminate, suspend, change or

reduce the current benefit, allocation or budget, including a reduction in LOC, or transfer or

discharge of a member residing in a residential facility. If applicable, cite NMAC rules or other

criteria that support the basis of the decision. Include the date the benefit will stop or otherwise

change. A letter is required even if the change is to increase a benefit or if there has been a new

review and the same benefit is extended.

If the action is a denial, in whole or in part, of a new benefit or service for the member, describe

what was requested and what has been denied or otherwise limited. If applicable, cite NMAC rules

or other criteria that support the basis of the decision.

An MCO contact, including email and mail addresses, fax and telephone numbers. Include the hours

this contact is available, as well as an emergency number. Inform the member to use this contact

information if he or she has any questions. Inform the member how to access toll-free numbers with

TTY/TTD and interpreter capability.

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Notice of the right to file an Appeal should include:

If the member disagrees with the Action, he or she has the right to appeal the decision to the MCO.

If the member would like to Appeal the decision, the Appeal must be requested within 60 calendar

days of the date of the Notice of Action. Include information that if the member misses the

deadline, they may lose their right to appeal. Offer to assist the member in requesting or filing for an

Appeal and tell them how he or she can obtain that assistance.

Describe the Standard Appeal process, including the request may be made by phone, but a written

request will need to be completed within 13 calendar days of the verbal request.

Describe the Expedited Appeal process, and that such a request may be made by phone.

Describe the criterion that merits an Expedited Appeal.

Inform the member of his or her right to a timely Appeal decision (not longer than 30 calendar days

from the request for a Standard Appeal or 72 hours for an MCO Expedited Appeal) and the

anticipated date of the Final Appeal Decision.

Provide appropriate forms for an Appeal that has the member identify how he or she would like to

be contacted.

Briefly describe the Appeal process:

Tell the member that he or she may file a Grievance even if he or she does not request an Appeal.

Clarify that the Grievance does not act as Appeal of any adverse action. Tell the member how to file

a Grievance.

Tell the member that he or she may file a Grievance and request an Appeal concurrently.

Provide an MCO Appeal contact which includes email and mail addresses, fax and phone numbers.

Include the hours that this contact is available, as well as an emergency number. Inform the

member to use this contact information if he or she has any questions. Inform the member how to

access toll-free numbers with TTY/TTD and interpreter ability.

Tell the member that if he or she requests an Appeal, he or she can obtain assistance from an

authorized representative, authorized provider, designated spokesperson, or legal counsel. Provide

the appropriate form and describe the process to the member.

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Tell the member when the he or she requests an Appeal:

He or she the right to designate an authorized representative. The authorized representative can

have access to the case information and may make medical decisions on behalf of the member.

He or she has the right to designate an authorized provider who agrees to assist him or her. The

authorized provider can have access to the case information, but does not have the authority to

make medical decisions on behalf of the member.

He or she has the right to designate a spokesperson. The spokesperson may have access to case

information and may speak for the member, but does not have the authority to make medical

decisions on behalf of the member.

He or she has the right to present evidence and testimony and make legal and factual arguments on

the issue before the MCO makes a final determination on the Appeal. This presentation may be

made by the member, a spokesperson or any designated or authorized representative. The member

or authorized must make a request for this presentation and that the MCO will schedule this

presentation prior to making a final decision on the appeal. The MCO must tell the member of the

limited time the member has to make this request in order that the MCO can provide the decision

within the required time frame; and of the member’s option to extend the time frame for up to an

additional 14 calendar days.

Neither an MCO or HSD can be held responsible for any fees or costs incurred by the member during

the MCO Expedited or Standard Appeal process.

Notice of the Right to Continuation of Benefits when there is an Adverse Action:

If the Action is to terminate, suspend, or reduce the current benefit, allocation or budget, including a

reduction in LOC, or transfer or discharge of a member residing in an NF, the letter must include a notice

of the right to a continuation of benefits:

If the benefit is already being provided, inform the member that he or she can request a

continuation of benefits at any time prior to the date the benefit will be terminated based on

the Notice of Action. (Note that if the Appeal is initiated by the MCO, the continuation of

benefits is automatic and the member never pays for using the continued benefit.)

Inform the member if he or she requests a continuation of benefits, the member will continue

to receive his or her disputed current benefit during the Appeal process, but the member may

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choose to end his or her continued disputed benefit at any time during the MCO Appeal process

or HSD Administrative Hearing.

Explain the process to request a continuation of his or her disputed current benefit including

time frames.

Provide a phone number to verbally request a continuation of the disputed current benefit and

a mailing or email address, or fax number to submit a written request for a continuation of the

disputed current benefit.

Provide the MCO member with contact information, the type of disputed current benefit, the

number of times a day, week or month the member receives the disputed current benefit, the

length of time the benefit is delivered, the LOC of the benefit, or the allocation or budget

amount received.

Include information on the recoupment of the cost of the member’s continued disputed current

benefit if the MCO’s final decision upholds, in whole or in part, its adverse action; and state that

if the member later requests an HSD Administrative Hearing in which the final decision upholds

the adverse action, in whole or in part, the member will be financially responsible for paying for

the services they used.

When the MCO is initiating an MCO Expedited Member Appeal on behalf of the member, in addition

to all other requirements, the MCO must:

Inform the member of the process of an MCO-initiated Expedited Member Appeal.

Inform the member that the MCO is continuing the member’s disputed current benefit throughout

the MCO-initiated Expedited Appeal process and that the member is not obligated to repay the

continued disputed current benefit if the MCO Member Appeal Final Decision upholds the action.

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16.3.4. MCO Checklist for Notice of Action Letter to Member Regarding VAS

MCO Checklist for Notice of Action Letter to Member Regarding Value-Added Services

Notice of Action should include:

The date of the Notice, which should be consistent with the date the Notice will be mailed. If the

Notice is to terminate an existing benefit, the date must be no less than 10 calendar days prior to the

date the benefit will end.

Describe what action the MCO intends to take or has taken to terminate, suspend, change or reduce

the current value-added benefit. If applicable, cite NMAC rules or other criteria which may support

the basis of the decision. Include the date the benefit will stop or otherwise change. A letter is required

even if the change is to increase a benefit or if there has been a new review and the same benefit is

extended.

If the action is the denial, in whole or in part, of a new benefit or service for the member, describe

what was requested and what has been denied or otherwise limited. If applicable, cite NMAC rules or

other criteria which may support the basis of the decision.

Include a statement that an MCO VAS adverse determination cannot be appealed through the MCO

or reviewed through an HSD Administrative Hearing.

If applicable, describe alternative MAD benefits that the member may utilize to replace the

terminated VAS.

Provide MCO contact, including email and mail addresses, fax and phone numbers. Include the hours

that this contact is available, as well as an emergency number. Inform the member to use this contact

information if he or she has any questions. Inform the member how to access toll-free numbers with

TTY/TTD and interpreter capability.

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16.3.5. MCO Checklist for the Acknowledgements of Member Appeals

MCO Checklist for the Acknowledgements of Member Appeals

The MCO should have, at a minimum, six separate but similar letters:

• Acknowledgement of a written Standard Appeal;

• Acknowledgement of a verbal Standard Appeal;

• Acknowledgement of a Standard Appeal, but the MCO or member changes it to an Expedited

Appeal;

• Acknowledgement of an Expedited Appeal;

• Acknowledgement of an Expedited Appeal but Denying the Expedited Status; and/or

• Notice of an MCO initiated Expedited Appeal and Continuation of Benefits.

Requirements

An Appeal request must always be followed by an acknowledgement within 5 business days of receipt of

an Appeal. Copies of the acknowledgement and any associated documents must be sent to the member,

any authorized representative, and to the provider who requested the disputed benefit.

If the acknowledgement letter is in response to a verbal request for a Standard Appeal, the

acknowledgement must: contain information about the 13 calendar day requirement to submit a

written Appeal, include the fact that if the member misses that deadline, they may lose their right to

an Appeal, and an offer to assist the member with the written Appeal.

The MCO must provide the Appeal form and offer to assist the member if they need help

completing it. (A request in writing from the member is not required for an Expedited Appeal.)

The Appeal acknowledgement must include the following:

The date of the acknowledgement, which should be consistent with the date the acknowledgement

letter will be mailed.

The date the Expedited or Standard Appeal request was received by the MCO and a brief statement

of the MCO’s understanding of the issue the member is appealing.

The anticipated date of the Appeal decision, which may be in the form of “no later than.”

The date of any scheduled informal conference to help clarify or settle the issue. Inform the member

they must adhere to the date or contact the MCO to change the date, if necessary. The scheduling of

an informal conference is not mandatory, but may be requested by the MCO.

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A MCO Appeal contact which includes email and mail addresses, fax and phone numbers. Include

the hours that these contacts are available, as well as any other emergency number that may be

available. Inform the member to use this contact information if he or she has any questions. Inform

the member how to access toll-free numbers with TTY/TTD and interpreter capability.

Inform the member of his or her right to have someone with them or to represent them in their

Appeal and that if they would like someone to represent them, they must make a request in writing.

Provide the appropriate form and describe the process to the member.

Inform the member of how to submit additional information regarding the issue, if the member or

provider has more information to provide.

Inform the member of his or her right to a continuation of benefits if the benefit is already being

provided and the member has not already requested a continuation of the disputed current benefit.

(This information should have also been previously provided in the Notice of Action.) Inform the

member that he or she can request a continuation of benefits at any time prior to the date the

benefit will be terminated, based on the Notice of Action, or within 10 calendar days of the date of

the notice, whichever is the longer period of time. (Note that if the Appeal is initiated by the MCO,

the continuation of benefits is automatic and the member never pays for using the continued

benefit.)

Inform the member if he or she requests a continuation of benefits, the member will continue to

receive his or her disputed current benefit during the Appeal process. Include information on the

recoupment of the cost of the member’s continued disputed current benefit if the MCO’s final

decision upholds, in whole or in part, its adverse action; and state that if the member later requests

an HSD Administrative Hearing if the final decision upholds the adverse action, the member will be

financially responsible for paying for the services they used.

Provide the member with contact information for requesting a continuation of benefits.

Inform the member that he or she may choose to end his or her continued disputed benefit at any

time during the MCO Appeal process or HSD Administrative Hearing process.

Include a statement of the member’s rights that includes the following:

The member’s right to a timely decision on the Appeal; a decision must be provided within 30

calendar days from the request for a Standard Appeal or 72 hours from the request for an Expedited

Appeal, unless notice is provided by the member or the MCO that additional time is required.

Section 16: Fair Hearings

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

360 | P a g e

That either the member or the MCO have the right to extend the time frame up to 14 calendar days

if necessary, but if the MCO extends the time frame, the member has the right to file a Grievance

with the MCO, if he or she disagrees with the extension.

That if the member believes that their health or life is endangered while awaiting a decision, the

member at any time during the appeal process can ask for a “quick” decision by requesting the

Appeal be changed to an Expedited Appeal, in which a decision is usually made within 72 hours; or if

it is an emergency, the decision will be made as soon as possible.

Outline the process that can occur if the Appeal decision is not in the member’s favor:

State that after the MCO Appeals process, if the member would like to continue the Appeal, he or

she may do so by requesting:

An HSD Expedited Administrative Hearing within 30 calendar days of the date of the MCO

Member Appeal Final Decision;

An HSD Standard Administrative Hearing within 90 calendar days of the date of the MCO

Member Appeal Final Decision; and/or

That more information on requesting an HSD Administrative Hearing will be included in the

Appeal Decision Letter if the decision is not in favor of the member.

Inform the member that he or she may also request for an HSD Administrative Hearing, if the

decision on their Appeal is not timely.

Inform the member that he or she may file a request for an HSD Administrative Hearing if the

member requested an Expedited Appeal, but the MCO denies the expedited status. The HSD

Administrative Hearing will be limited to the issue of expediting the MCO Appeal decision.

The acknowledgement must be in clear and simple verbiage. If the MCO has a packet of information

accompanying the letter, some of the detailed information may be in the packet rather than in the

letter, as long as the letter directs the member to look there.

Section 16: Fair Hearings

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

361 | P a g e

16.3.6. MCO Checklist for Letter Informing the Member of a Delay for an Appeal Decision

MCO Checklist for Letter Informing the Member of a Delay for an Appeal Decision

The Letter should include:

The date of the letter, which should be consistent with the date the letter will be mailed. If the

pending Appeal Decision is regarding termination of an existing benefit, the date must not be less

than 10 calendar days prior to the date the benefit will end. It is also a requirement to make a

reasonable effort to provide the member with information regarding the delay orally, in addition to

the written Acknowledgement.

Describe what action the MCO intends to take or has taken to terminate, suspend, change or reduce

the current benefit, or for a new benefit, intends to deny or limit.

Include the new date the benefit will terminate or otherwise change, if a delay in a decision is going

to delay the date of the benefit change or termination. A letter is required even if the change is to

increase a benefit or if there has been a new review and the same benefit is extended.

State the date a decision was due and the length of time the decision will be delayed. Include the

date a final decision is expected. Include the justification of why the decision is being delayed.

Tell the member that if he or she disagrees with the delay, they have the right to file a Grievance.

Describe the process on how they do so, including any forms that are necessary.

Provide an MCO contact, including email and mail addresses, fax and phone numbers. Include the

hours that this contact is available, as well as an emergency number. Inform the member to use this

contact information if he or she has any questions. Inform the member how to access toll-free

numbers with TTY/TTD and interpreter capability.

Tell the member that if the MCO does not provide a decision within the required 14 calendar day

extended time frame, the member has the right to request an HSD Administrative Hearing which will

result in the Administrative Hearing process making the final decision on the issue being appealed.

Section 16: Fair Hearings

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

362 | P a g e

16.3.7. MCO Checklist for the MCO Member Appeal Final Decision Letter

MCO Checklist for the MCO Member Appeal Final Decision Letter

The MCO should have, at a minimum, three separate but similar letters:

• Reversal of MCO Adverse Action;

• Partial Reversal of MCO Adverse Action; and

• No Reversal of MCO Adverse Action.

1. Letter for Reversal of MCO Action and Approval of the Benefit. Include in the notice of the

reversal of the MCO’s adverse action:

The date of the letter, which should be consistent with the date the letter will be mailed.

The date that the disputed benefit will start if the benefit was not continued or supplied during the

appeal process.

A MCO contact in case the member has any questions. Include email and mail addresses, fax and

phone numbers, the hours that the contact is available, and an emergency number if one is

available. Inform the member to use this contact information if he or she has any questions. Inform

the member how to access toll-free numbers with TTY/TTD and interpreter capability.

2. Letter for partial reversal of MCO Adverse Action.

Approved Benefit:

Inform the member of the date the disputed benefit will start if the benefit was not continued or

supplied during the appeal process.

Provide an MCO contact in case the member has any questions. Include email and mail addresses,

fax and phone numbers, the hours that the contact is available, and an emergency number if one is

available. Inform the member to use this contact information if he or she has any questions. Inform

the member how to access toll-free numbers with TTY/TTD and interpreter capability.

Denied Benefit:

Inform the member what disputed benefit was denied. State the date the denied benefit will be

terminated if it is currently being supplied.

Include a statement describing any rationale for the decision to deny the disputed benefit.

If applicable, cite NMAC rules or other reasoning used to make the final decision.

If the member had a continuation of benefits, inform the member what the recoupment cost is and

how the MCO will start recoupment.

Section 16: Fair Hearings

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

363 | P a g e

Provide an MCO contact who can explain the recoupment process and who can assist the member

to request an HSD Administrative Hearing if the member chooses to do so. Include email and mail

addresses, fax and phone numbers, the hours that the contact is available, and an emergency

number. Inform the member to use this contact information if he or she has any questions. Inform

the member how to access toll-free numbers with TTY/TTD and interpreter capability.

Include Member Rights and Information to Request an HSD Administrative Hearing: Include the

same information in that letter as described below, under the “Letter Upholding the Action.”

3. Letter Upholding the Action:

Include a statement describing the rationale to deny the disputed benefit.

If applicable; cite NMAC rules or other reasoning used to make the final decision.

Inform the member of the date the denied benefit will be terminated if it has been continued during

the Appeal.

If the member had a continuation of benefits, inform the member what the recoupment cost is and

how the MCO will start recoupment.

Provide an MCO contact who can explain the recoupment process and who can assist the member

to request an HSD Administrative Hearing if the member chooses to do so. The contact information

must include email and mail addresses, fax and phone numbers, the hours that the contact is

available, and an emergency number. Inform the member to use this contact information if he or

she has any questions. Inform the member how to access toll-free numbers with TTY/TTD and

interpreter capability.

Inform the member that he or she may choose to end his or her continued disputed current benefit

at any time prior to and during the HSD Administrative Hearing process.

Inform the member that they may request an HSD Standard Administrative Hearing within

90 calendar days of the date of the MCO Expedited or Standard Member Appeal Final Decision

letter.

Inform the member they may request an HSD Expedited Administrative Hearing within 30 calendar

days of the date of the Appeal Final Decision letter. The request for an HSD Expedited Administrative

Hearing may be made verbally or in writing.

Provide the member with the HSD Fair Hearing Bureau email and mail addresses, fax and phone

numbers, HSD toll-free numbers with TTY/TTD and interpreter capability.

Section 16: Fair Hearings

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

364 | P a g e

Inform the member that if they request an HSD Administrative Hearing, the MCO will not take steps

to recoup the cost of the member’s current disputed benefit until the HSD Administrative Hearing

process is over, unless requested to do so by the member.

Inform the member he or she may choose to end his or her continued disputed current benefit at

any time prior to and during the HSD Administrative Hearing process.

Inform the member of the recoupment of the cost of the member’s continued disputed current

benefit if the HSD Administrative Hearing Final Decision letter upholds the MCO’s Action.

All letters must be in clear and simple verbiage. If the MCO has a packet of information accompanying

the letter, some of the detailed information may be in the packet, as long as the letter directs the

member to look there.

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

365 | P a g e

17. Managed Care Reporting

17.1. General Information

MCOs are required to comply with all reporting requirements established by HSD as specified in the

Agreement, which details requirements for timely submission, formatting, completeness and accuracy

of content. MCOs are provided with State-approved instructions and templates to facilitate timely,

complete, and accurate reporting. A complete list of current reports is incorporated in this Manual as

17.8.1: Centennial Care MCO Reports.

17.2. General Requirements

HSD, at its discretion, may request information and/or data, identified as ad hoc requests. Ad hoc

requests are issued to the MCOs for various reasons and information is generally requested to address a

separate and distinct issue or to provide clarification on issues that fall outside the scope of reporting

(i.e., provider information, claims research, NF census, etc.).

MCOs are required to implement continuous improvement processes to identify instances and patterns

of non-compliance. Identified patterns of non-compliance are addressed internally by MCOs to improve

overall performance and compliance.

At its discretion, HSD may, at any time, revise existing report content, and HSD may seek MCO input on

proposed changes. Once HSD issues finalized Report Instructions and Templates, MCOs will have at least

14 calendar days, and additional time at HSD’s discretion, to implement report content changes

depending on the nature of the changes.

17.3. MCO Reporting and Intake

HSD’s report management process involves the following:

• Downloading MCO report submissions via Xerox secure File Transfer Protocol (FTP) site;

• Processing MCO report submissions, resubmissions and other related documents;

• Acknowledging receipt of reports within 45 calendar days of receipt of the report upload date;

• Performing an initial quality check to ensure the MCO report is timely, accurate, complete,

formatted correctly, submitted on the correct template version and is accompanied by a signed and

dated Attestation;

• Recording all report review information and actions into an MCO Reports Tracking Tool;

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

366 | P a g e

• Assigning MCO reports to Subject Matter Experts (SMEs) who possess the knowledge and

experience to conduct a thorough analysis of MCO reports and verify MCO compliance with HSD

requirements and performance standards;

• Tracking and monitoring the MCO report review and data analysis process;

• Managing HSD Lead Report Reviewer timeframes; and

• Uploading HSD feedback (Acceptance, Rejection, Final Review Tool, etc.) to the FTP site.

17.4. Report Rejection

An MCO Report may be rejected, by HSD, due to the following reason(s):

• Data inaccuracies;

• Signed Attestation not included;

• Incomplete information (e.g., data missing in fields);

• Formatted incorrectly;

• Incorrect template;

• Incorrect naming convention; and/or

• Incorrect reporting period, MCO name and report run date.

The HSD Contract Manager will determine whether a Rejection is warranted, or if a technical assistance

call or other solution is preferred.

17.5. MCO Report Resubmission

HSD has developed and implemented several processes (technical assistance call, self-identified error

resubmission [SIER]) to allow for improvement of the MCOs’ data accuracy and reporting compliance.

Technical Assistance Call Process

HSD Contract Managers and SMEs are available to provide technical assistance to MCOs in the following

areas:

• Review of HSD feedback of reports;

• Discuss extension requests of report submission deadlines; and

• Press to resolve reporting concerns;

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

367 | P a g e

In an effort to maximize and improve MCO reporting and data efficiency levels, HSD may conduct a

technical assistance call to address data-related questions and concerns. This provides an opportunity

for MCOs to gain valuable guidance from HSD Contract Managers and SMEs.

After a technical assistance Call is held, the HSD Contract Manager determines whether the MCO’s

report is Accepted or Rejected.

Self-Identified Error Resubmission

In addition to Section 4.21.1.6 of the Agreement, MCOs must upload a SIER report within the deadline

specified by an HSD Contract Manager.

MCOs are required to accurately label each subsequent report submission with the appropriate version

number (v2, v3, v4).

HSD Contract Managers approve all MCO Report Rejections and SIERs; manage the technical assistance

call process; and direct the overall resubmission of MCO reports.

17.6. Report Revisions

HSD conducts report revisions as necessary through a formal, written process in which MCOs and end

users request needed changes to data reporting metrics. This process is intended to streamline

managed care reporting and reduce administrative burden by limiting data collection, where possible, to

meet Federal and state requirements. Changes to HSD’s managed care data reporting also support the

needs of external agencies and stakeholders.

The report revision process begins with submission of a formal request to HSD. If the request is

approved, the Centennial Care Contracts Bureau will organize a revision workgroup with SMEs and

report reviewers to make required revisions or modifications.

When the workgroup completes this function, a draft reporting package is submitted to MCOs for

comment and testing. Comments may be rejected or accepted, resulting in additional revisions to the

reporting package. HSD then issues the final reporting package to MCOs for implementation.

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

368 | P a g e

17.7. System Availability Reporting

MCOs must notify HSD of MCO’s and its subcontractor’s systems availability and performance. In the

event of scheduled unavailability of critical member and provider Internet and/or telephone-based

functions and information, including but not limited to member eligibility and enrollment systems,

MCOs must notify HSD in advance via email at HSD.MCOSystemsAvail@State.nm.us in order to obtain

approval by HSD. In the event of an unforeseen and unscheduled inaccessibility of any critical systems,

MCOs must notify HSD via email to the above address as soon as possible.

Furthermore, in the event of a problem with system availability that exceeds four hours, MCOs are

directed to notify HSD immediately via email at HSD.MCOSystemsAvail@state.nm.us. MCOs are to

provide HSD within five business days, documentation that includes a CAP describing how MCO will

prevent the problem from occurring again.

In the event of any critical systems unavailability that has been approved by HSD but the amount of

downtime exceeds what was initially approved by HSD, MCOs must notify HSD immediately via email at

HSD.MCOSystemsA[email protected].

During Federal and/or State Holidays and weekends, the same processes included above would apply.

For any critical member or provider system unavailability, MCOs should also immediately contact

John Padilla, MAD, at (505) 827-1340 and email him at JohnH.Padilla@state.nm.us.

For any email notification pertaining to the above direction, MCOs must use the HSD-developed

template included in this Section as 17.8.2: Systems Availability Incident or Event Report.

17.8. Appendices

17.8.1 Centennial Care MCO Reports

17.8.2 Systems Availability Incident or Event Report

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

369 | P a g e

17.8.1. Centennial Care MCO Reports

Report

No.

Report Title

Frequency

Report Objective

Comment

Native American Members

Report

Quarterly

To ensure Native American members have access to care and are receiving

needed services.

Call Center

Report - Monthly

Monthly

To capture call center statistics and ensure that callers can access a call

center agent in a timely manner.

Network Adequacy Report

Quarterly

To monitor the MCO’s compliance in maintaining an adequate and efficient

provider network, tracking new and terminated providers and single-case

agreements.

Self-Directed Report

Quarterly

To (i) monitor the amount of the annual SDCB budget used by members, (ii)

identify the services that are highly utilized, (iii) identify members that have

over-utilized or under-utilized their annual CB budget, and (iv) identify

members whose cost of care in the community is greater than 80% of the

cost of care in a private NF.

Admissions and

Readmissions Report

Quarterly

To monitor the number of members who are readmitted to a facility such as,

an RTC, TFC, hospital, within 30 calendar days of a previous discharge and to

track follow-up appointments after discharge.

Care Coordination Report

Quarterly

The Care Coordination report monitors assessments, ongoing care

coordination activities, and changes of care coordination levels for all levels

of care coordination.

On Hold

Level of Care (LOC) Report

Monthly

To capture data regarding the nursing facility (NF) LOC determination

process including timeframes, activities of daily living, and care settings.

Agency-Based Community

Benefit (ABCB) Report

Quarterly

To (i) monitor the number of members that changed to ABCB, (ii) identify

the services used by members receiving ABCB, and (iii) identify members

whose cost of care in the community is greater than 80% of the cost of care

in a private NF.

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

370 | P a g e

Report

No.

Report Title

Frequency

Report Objective

Comment

Provider Satisfaction

Survey Report

Annually

To review the results from the survey, including information regarding

overall satisfaction (claims, provider relations, network, utilization and

quality management, pharmacy and drug benefits, and continuity of care).

Audited HEDIS Results

Annually

To monitor and review audited HEDIS results.

UM Program Description,

Associated Work Plan and

Evaluation

Annually

To monitor the MCO's UM Program Evaluation to monitor overall

effectiveness, an overview of UM activities, and an assessment of the impact

of the UM program on management and administrative activities. The

MCO’s review and analysis shall be incorporated in the development of its

following year’s UM Work Plan.

UM Program Evaluation

Annually

To evaluate the overall effectiveness of UM including an overview of UM

activities and an assessment of the impact of the UM program on

management and administrative activities.

LOD #29: Combined with 18

Disease Management

Description and Evaluation

Annually

To monitor and review the MCO's Disease Management program which

includes a description of MCO activities regarding chronic conditions

identified in the Disease Management program description. Disease

Management is a component of care coordination and must include BH as

part of the program.

Disease Management

Annual Evaluation

Annually

To evaluate the MCO's Disease Management program.

LOD #29: – Combined with 20

QM/QI Program

Description and

Associated Work Plan

Annually

To monitor and review the MCO's Annual QM/QI Program Description and

Associated Work Plan to include goals, objectives, structure, and policies

and procedures that address continuous QI for PH and BH.

QM/QI Program Annual

Evaluation

Annually

To monitor the MCO's QM/QI Program Evaluation for the previous year's

activities.

CAHPS Results Report

Annually

To review and evaluate the Consumer Assessment of Healthcare Providers

and Systems (CAHPS) results report.

Activities of the Member

Advisory Boards

Semi Annually

To review Member Advisory Board meeting agendas for general MCO

membership, Native American representation, BH, and CB subgroups.

LOD #29: Report 27 Combined

with 27a and 32; now

semi-annually.

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

371 | P a g e

Report

No.

Report Title

Frequency

Report Objective

Comment

27a

Subgroup of the Member

Advisory Board (BH,

Self-Directed, etc.)

10 business

days following

each meeting

To Monitor the activities of subgroups of the Member Advisory Board.

LOD #29: Combined with 27 and

32.

Health Education

Evaluation Report

Annually

To evaluate the MCO's Health Education Plan, relating to initiatives in the

plan and present findings, lessons learned and performance improvement

initiatives as a result of the findings.

LOD #29: Combined with 30.

Activities of the Native

American Advisory Board

Report

10 business

days following

each meeting

To monitor the activities of the Native American Advisory Board, including a

summary of the MCO's approach to inviting Native American advisory

members, the meeting agenda, minutes, attendees and scheduling of the

next meeting.

LOD #29: Combined with 27 and

27a.

Electronic Visit Verification

(EVV)

Quarterly

To review and evaluate the use of EVV systems of the MCOs.

Critical Incidents

Report - Quarterly

Quarterly

To monitor key metrics regarding critical incident reporting for specific

subpopulations and the MCO’s actions in response to critical incidents.

LOD #29: Report Number changed

from 36B to 36.

Grievances and Appeals

Report

Monthly

To monitor member and provider grievances, appeals and fair hearings and

to track MCO adherence to contractual timeframes.

Provider Training and

Outreach Plan and

Evaluation Report

Annually

To monitor and review the MCO's plans for provider training and outreach.

Provider Training and

Outreach Plan Evaluation

Report

Annually

To evaluate specific training topics such as (i) prior authorization process, (ii)

claims/encounter data submission(iii) how to access ancillary providers; (iv)

members rights and responsibilities; (v) quality improvement (QI)

program/QI initiatives; (vi) provider and Member Appeals and Grievances;

(vii) recoupment of funds processes and procedures; (viii) Critical Incident

management; and (ix) EPSDT benefit requirements, including preventative

healthcare guidelines.

LOD #29B:

Combined with #38

Prior Authorization Report

Quarterly

To capture information on services requiring prior authorization and

examine changes and trends in authorizations and denials of services over

time.

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

372 | P a g e

Report

No.

Report Title

Frequency

Report Objective

Comment

Pharmacy Report

Monthly

To monitor pharmacy utilization and cost, including dispensing fees,

over- and under-utilization of drugs including controlled substances,

utilization of formulary drugs, non-formulary drugs, over the counter,

generic, and brand drugs.

BH Members Services/CSA

Report

Quarterly

To monitor the number and types of members served through CSAs and the

types of services provided to such members.

On Hold

Pending Revision

Claims Activity Report

Quarterly

Claims Activity Section – To capture data related to the disposition of claims,

timeliness of claims adjudication, payments on clean claims to providers,

interest paid, and claim aging. This section of the report captures claims

data separately for PH providers, BH providers, I/T/Us (Indian Health Service,

Tribal health providers, and Urban Indian providers), and specialty-pay

providers (day activity providers, assisted living providers, nursing facilities,

home care agencies, and CB providers).

Claims Payment Accuracy Section – To report the findings of the MCO’s

internal audit of quarterly claim payments and to monitor the accuracy of

those claims paid.

LOD #29 C: Frequency of

submission changed from

Monthly to Quarterly

Patient Centered Medical

Homes (PCMH) Report

Quarterly

To track (i) the number of PCMHs established, (ii) the number of members

that were referred to and joined a PCMH, (iii) outcomes, including

emergency room utilization and hospital admission and readmission, and (iv)

PCMH NCQA recognition and other accreditation.

LOD #29: Frequency of

submission changed from

Semi-Annually to Quarterly

Provider Network

Development,

Management Plan and

Evaluation

Annually

To monitor and review the MCO's plans for developing and managing its

provider network to ensure all medically necessary services are accessible

and available.

Provider Network

Development and

Management Evaluation

Report

Annually

To evaluate the Provider Network Development and Management Plan that

provides information on a summary of providers, monitoring activities,

contract provider issues, network deficiencies and on-going activities for

provider development and expansion.

LOD #29: Combined with 49

Provider Suspensions and

Terminations Report

Semi Annually

To monitor the suspensions and terminations of providers and the number

of members impacted.

LOD #29: Frequency of report

submission changed from

Quarterly to Semi-Annually

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

373 | P a g e

Report

No.

Report Title

Frequency

Report Objective

Comment

PCP Report

Quarterly

To capture information regarding PCP member ratios, open panels and

assignment/change activity for non-dual members.

LOD #29: Frequency of

submission changed from

Monthly to Quarterly

Geo/Access Report

Quarterly

To monitor access to services by county and across urban, rural, and frontier

counties.

Program Integrity Report

Quarterly

To monitor fraud, waste, and abuse cases, preliminary investigations,

suspicious activities, adverse actions, and financial program integrity

activities of the managed care organization.

Medicaid School-Based

Health Centers (SBHC)

Quarterly

To track the quantity and types of services billed by school-based health

centers.

On Hold – LOD #29 (pending

revision)

Developmental Disabilities

(DDs) Specialty Dental

Report

Quarterly

To monitor dental visits for members with DDs.

Jackson Class Members

Report

Quarterly

To monitor MCO performance in processing requests for and delivering new

adaptive equipment and modifications or repairs to adaptive equipment.

Health Homes (HHs)

Report

Quarterly

To track (i) the number of HHs established; (ii) the number of members

referred to and joined a HH (iii) outcomes, including emergency room

utilization and hospital admissions and readmissions.

On Hold – LOD #29

This report is in development

Section 17: Managed Care Reporting

Revision dates: August 15, 2014; March 3, 2015;

January 1, 2019

Effective dates: January 1, 2014

374 | P a g e

17.8.2. Systems Availability Incident or Event Report

Section 18: Quality

Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

375 | P a g e

18. Quality

18.1. Performance Improvement Projects (PIPs)

In addition, to the three PIPs outlined in the Agreement (one related to long-term services, one related

to prenatal and postpartum, and one related to adult obesity), the MCO shall be required to do the

following two PIPs based on the most current CMS Adult Core Set.

• Diabetes prevention and enhanced disease management:

o PQI01-AD: Diabetes, Short-Term Complications Admission Rate (NQF #0272); and

o HA1C-AD: Comprehensive Diabetes Care: Hemoglobin A1c Testing (NQF #0057)

• Screening and management for clinical depression

o AMM-AD: Antidepressant Medication Management (NQF #0105); and

o CDF-AD: Screening for Clinical Depression and Follow-Up Plan (NQF #0418)

These PIPs shall follow all CMS EQR protocols and will be reviewed annually by the EQRO based on the

most current EQR protocols.

18.2. Provider Satisfaction Survey

The Provider Satisfaction Survey is an annual report that provides the MCO with an assessment of its

activities, policies and procedures related to identifying healthcare performance, improvements and

internal systems based upon satisfaction of its contracted providers. HSD has outlined specific

requirements to be included in the provider satisfaction survey. Those requirements are incorporated

into the Provider Satisfaction Survey reporting instructions. The survey requirements list the detailed

description of:

• Three populations to target;

• Rating system to follow;

• Topics to address; and

• Template of the required questions, which are attached in 18.4.1.

Section 18: Quality

Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

376 | P a g e

18.3. Critical Incident Reporting

All agencies in New Mexico providing HCBS and BH services are required to report Critical Incidents

within 24 hours of knowledge of the occurrence. The critical incident(s) should be reported to the

member’s MCO and/or Adult Protective Services (APS) or Child Protective Services (CPS) as necessary.

Critical incident reporting responsibilities and reporting requirements include:

• HCBS critical incidents involving members with a qualifying COE must be reported on the HSD

Critical Incident Reporting System for the following reportable incidents: abuse; neglect;

exploitation; deaths; environmental hazards; missing/elopement; law enforcement; and emergency

services.

o Qualifying COEs include: 001; 003; 004; 081; 083; 084; 090; 091; 092; 093; 094; 100; and 200

with a NF LOC.

• Critical Incident Reports filed as the result of a member's death and accepted for investigation by

the Office of the Medical Investigator (OMI) shall remain in a pending state within the HSD Critical

Incident Reporting Portal until the OMI has issued its findings. The MCO is responsible to update

the HSD Critical Incident Reporting Portal with the results from the OMI.

• The MCO shall require all staff and Contracted Providers to document updates regarding initiated

action(s) taken for the member and all follow-up activities related to the intervention(s)

implemented as a result of the incident. The information should be entered into the HSD Critical

Incident Reporting Portal until the established intervention(s) demonstrate the member's health,

safety and welfare are no longer issues of concern.

o The follow-up action(s) include but are not limited to:

• Requiring an investigation or intervention for issues of health and safety;

• Information related to the member’s health, safety and welfare;

• Communication with internal or external agencies; and

• Any changes in the member's health status, including but not limited to; care

coordination visits or care coordination investigations or interventions, and/or

reassessment or change in the member’s comprehensive care plan.

• BH critical incidents and all Sentinel Events are defined by the BH Critical Incident Protocol.

o Critical incidents involving BH services for members with a non-qualifying COE must be

reported on the Centennial Care Behavioral Health Critical Incident form for any known, alleged

Section 18: Quality

Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

377 | P a g e

or suspected events of abuse, neglect, exploitation, injuries of unknown origin or other

reportable incidents.

o The MCO shall have a process and designate one fax line to receive critical incident reports

from BH providers for Medicaid recipients. The MCO shall provide this fax number to HSD and

the MCO contracted BH provider network.

o The MCO is responsible for reviewing and ensuring complete follow up has occurred regarding

all submitted BH critical incidents reported by or on behalf of their members, including APS and

CPS.

o The MCO will notify BHSD of all Sentinel Events in accordance with the BH Critical Incident

Protocol.

• Critical Incident Reporting Upon Termination of MCO Contract

o The MCO shall submit a report to HSD containing identified Critical Incident Reports

(CIRs) and any pending death investigations associated with its members thirty (30)

Calendar Days prior to the termination of the MCO contract, using a template provided

by HSD. The MCO shall submit weekly updates regarding these outstanding CIRs until all

reports are resolved and closed.

o The MCO shall be responsible for completing all follow-up activities, such as

investigations and final reporting of unresolved critical incidents for members who were

part of the MCO's membership at the time the incident was filed.

o Sixty (60) Calendar Days after the resolution of all outstanding Critical Incident Reports

and death investigations, the MCO's access to the HSD Critical Incident Reporting Portal

will be terminated.

18.4. Appendix

18.4.1 Centennial Care Reporting Survey Template

Section 18: Quality

Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

378 | P a g e

18.4.1. Centennial Care Reporting Survey Template

Centennial Care Reporting Survey Template

MCO survey results shall utilize the following rating system:

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

The survey shall include the following required questions:

Care Coordination/Continuity of Care

Effectiveness of MCOs care coordination/care management programs for members.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Assistance provided by care coordination/care management staff.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

MCO provides information needed to care for its members.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Overall Satisfaction

Likelihood you would recommend the MCO to other members?

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Likelihood you would recommend the MCO to other physicians?

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Overall satisfaction with MCO.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Claims

MCOs accuracy of claims processing.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Section 18: Quality

Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

379 | P a g e

MCOs timeliness of claims processing.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

MCOs timeliness of adjustment/appeal claims processing.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Ease of resolving claims issues without making multiple inquiries.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Provider Relations

MCOs process of obtaining member information (eligibility, benefit coverage, co-pay amounts).

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Satisfaction with MCOs customer service in answering questions and/or resolving problems when calling the

MCO.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

MCOs frequency and effectiveness of provider representative visits to the provider’s office.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Usefulness of MCOs written communications, policy bulletins, and manuals.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Quality of provider orientation and education processes.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Ease of completing MCO credentialing and re-credentialing.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

MCOs attentiveness to the provider’s overall needs.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Section 18: Quality

Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

380 | P a g e

Provider Network

Quality of the MCO’s primary care practitioners.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Quality of the MCO’s specialists.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

The number of quality specialists to whom the provider can refer patients.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

The number of specialists in the MCO’s provider network.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Utilization/Quality Management

Ease of the prior authorization process.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Timeliness of obtaining outpatient authorization of services.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Timeliness of obtaining inpatient authorization of services.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Satisfaction with coordination of home health and DME services.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Procedures for obtaining pre-certification/referral/authorization information.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Degree to which the plan covers and encourages preventive care and wellness.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Section 18: Quality

Revision dates: August 15, 2014; March 3, 2015,

January 1, 2019; October 1, 2020

Effective dates: January 1, 2014

381 | P a g e

Clinical appropriateness of UM decision.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Pharmacy/Drug Benefits

Ease of using formulary.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Ease of the pharmacy prior authorization process.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

MCOs variety of drugs available in formulary.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Timeliness of response to pharmacy prior authorization requests.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Extent to which formulary reflects current standards of care.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Ease of prescribing preferred medications within formulary guidelines.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Availability of comparable drugs to substitute those not included in the formulary.

Excellent – 6 Very Good – 5 Good – 4 Fair – 3 Poor – 2 Don’t know – 1

Section 19: Program Integrity

Revision dates:

Effective date: January 1, 2019

382 | P a g e

19. Program Integrity

19.1. General Information

The Centennial Care MCOs shall comply with all Program Integrity provisions of the Patient Protection

and Affordable Care Act (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act

of 2010 (P.L. 111-152) (collectively "PPACA "), and its regulations.

19.2. Fraud, Waste and Abuse Requirements

This section provides further guidance to the Agreement and clarifies the requirements set forth in the

following sections of the Agreement: 4.17.1 (Program Integrity - General); 4.17.2 (Program

Integrity - Reporting and Investigating Suspected Fraud and Abuse); and 7.27 (Cooperation Regarding

Fraud).

Provider profiling, auditing and data mining must occur on a regular basis to assist in the identification

of potential fraud, waste and abuse. This includes, but is not limited to, an automated review of claims

or a clinical audit. Information may also be used from external sources. When an MCO identifies

potential fraud, or becomes aware of an allegation of potential fraud or suspicious activity, it must

comply with the following:

Initial Report

• For PH or LTC services, make an initial report within five business days from the time the MCO

identifies potential fraud, or becomes aware of an allegation of potential fraud or suspicious activity

to the New Mexico HSD, OIG’s Program Integrity Unit (PIU). The MCO must identify whether it is an

initial report.

• For BH services provided to Medicaid recipients, make an initial report within five business days

from the time the MCO identifies potential fraud, or becomes aware of an allegation of potential

fraud or suspicious activity to PIU and the New Mexico Behavioral Health Collaborative (the

"Collaborative"). The MCO must identify whether it is an initial report.

• The MCO must document the identification of potential fraud, or allegation of potential fraud or

suspicious activity on the HSD Program Integrity Report ("Report 56") pursuant to the "Centennial

Care Reporting Instructions Program Integrity- Report #56".

Section 19: Program Integrity

Revision dates:

Effective date: January 1, 2019

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MCO Investigation

• Once initially reported, the MCO must begin the investigation promptly in order to ensure that is

completed within 12 months, including all reports as required by the Agreement or set forth herein

(see, information below), from when the MCO identified potential fraud, or became aware of an

allegation of potential fraud or suspicious activity, from when it was initially reported to the PIU. The

MCO must use the PIU supplied Special Investigative Unit (SIU) Case Summary form when reporting

Fraud, Waste and Abuse to the PIU. The SIU Case Summary form may include, but is not limited to,

the following information:

o Date of the initial report to PIU;

o With each update to PIU, identify the report as an update and the date of the update;

o Provider(s), member(s), and/or caregiver(s) full name, and any other known names used, that

are the subject(s) of the referral;

o Any known relationships between provider(s), member(s), and/or caregiver(s) (i.e., business,

personal, etc.);

o If a provider, whether they are a billing or rendering provider, and the name(s), address,

telephone number of the reciprocal billing or rendering provider;

o If known, NPI, TIN, SSN, DOB, Medicaid/Medicare Provider Number, Medicare Number,

Medicaid Number, address, phone number, and/or product line for the subject(s) of the referral.

If not known, identify as "Unk";

o If known, the complainant's contact information to include, name, physical address, email

address and phone number. If not known, identify as "Unk";

o MCO's case file number, date the MCO opened the case, allegation description and code

number, and source of the complaint, i.e. hotline, letter, email, etc.;

o Verify whether the member, caregiver, or provider has been previously investigated during the

previous five years and summarize what was found previously;

o Identify and review claim(s), billing(s), and payment history, and summarize what was found;

o Identify and review internal policies and procedures, and summarize what was found;

o Identify and review provider's credentials and member's eligibility status, and summarize what

was found;

o Identify and review state rules, service definitions, and manuals, and summarize what was

found;

Section 19: Program Integrity

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Effective date: January 1, 2019

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o Determine if the MCO previously provided education to the provider or member as it relates to

the suspicious activities, and summarize what was found;

o Document all investigative findings in the SIU Case Summary form;

o Identify the total potential overpayment resulting from fraud and the time period for the claims

reviewed; and

o Identify whether the potential overpayment was recovered in whole or in part, and if in part,

the amount recovered and the remaining balance.

The information identified above is fundamental for the PIU to determine a credible allegation of fraud

and if the MCO has this information, it should be included in the MCO's SIU Case Summary form to the

PIU. The MCO should also identify and summarize those investigative steps taken that have no results

and include them in the MCO's SIU Case Summary form to the PIU.

• In conducting their investigation, the MCO should keep in mind the definition of a credible

allegation of fraud, 42 CFR 455.2, and the obligations for an investigation set forth in 42 CFR 455.14.

• During the time that the MCO is conducting its investigation, it shall provide the PIU, and when

appropriate the Collaborative, with updates as requested.

• Within the 12-month period and within 10 business days of completing their investigation, the MCO

shall report the results to the PIU, and when appropriate the Collaborative, using the SIU Case

Summary form and state whether the MCO determined:

o The allegations are unsubstantiated and no further action is recommended;

o The allegations resulted in a potential overpayment; or

o The allegations resulted in a referral to the PIU with a recommendation that a credible

allegation of fraud may have been identified.

The MCO will use their last significant investigative action resulting in information that is significant and

relevant to the investigation as the date their investigation was completed. This may include, but is not

limited to, interview, document analysis, document receipt, etc.

• Upon completion of their investigation, the MCO shall update Report 56 pursuant to the "Centennial

Care Reporting Instructions Program Integrity-Report #56".

Overpayments

• If, as a result of their investigation, the MCO determines that an overpayment exists, the MCO shall

report to the PIU, and when appropriate to the Collaborative, using the SIU Case Summary form:

o The overpayment amount;

Section 19: Program Integrity

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Effective date: January 1, 2019

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o The claims identified for overpayment recoupment such claims being reflected on the MCO's

encounter data;

o If the overpayment amount is extrapolated, the methodology used for the extrapolation;

o The date the provider was notified of the overpayment;

o The terms of any repayment; and

o Whether the overpayment was recovered in whole or in part, and if in part, the amount

recovered and the remaining balance.

• Providers may also self-disclose overpayments to the MCO as indicated in Section 4.17.4 (Recoveries

of Overpayments and/or Fraud) of the Agreement and 42 U.S.C. § 1320a-7k(d)(l), codifying Section

6402(a) of PPACA.

• All overpayments resulting from situations other than fraud, including self-reported overpayments

to the MCO, shall be considered the MCO's property unless:

o The HSD, OIG, CMS or its contractors, HSD's Recovery Audit Contractor, or the New Mexico

Attorney General's Office, Medicaid Fraud and Elder Abuse Division (MFEAD, also commonly

referred to as the Medicaid Fraud Control Unit) notified the provider that an overpayment

existed;

o The MCO fails to initiate recovery within 12 months from the date the MCO first paid the claim;

o The MCO fails to complete the recovery within 15 months from the date the MCO first paid the

claim.

Credible Allegations of Fraud

• If, as a result of their investigation, the MCO determines the allegations appear credible, a SIU Case

Summary form and all supporting documentation must be submitted to the PIU within 12 months

from when the MCO identifies potential fraud, or becomes aware of an allegation of potential fraud

or suspicious activity, and 10 business days from completion of the MCO's investigation. The MCO

shall also document the referral on Report 56 pursuant to the "Centennial Care Reporting

Instructions Program Integrity Report #56".

• If the PIU does not refer the matter to MFEAD or other law enforcement agency, the MCO may take

whatever action it deems appropriate, including but not limited to, seeking overpayment from the

provider and/or conducting educational training with the provider.

Section 19: Program Integrity

Revision dates:

Effective date: January 1, 2019

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• If the PIU refers the matter to MFEAD, the PIU shall, within 10 business days, notify the MCO of such

referral. Thereafter, the PIU shall attempt provide the MCO with quarterly updates based on the

State Fiscal Year cycle. This is in addition to any other requirements, including payment suspension,

as outlined in the Agreement, specifically 7.27.1.1. (Referrals for Credible Allegations of Fraud) of

the Agreement.

• If the PIU refers the matter to MFEAD and it is not accepted or it is later returned by MFEAD, the PIU

shall, within 30 calendar days notify the MCO. In such a situation, HSD, at its sole discretion and

related to administrative and civil remedy available to HSD, may seek recovery against the provider

for any overpayments and any refund shall be HSD's property. This is in addition to any other

requirements set forth in 7.27.1 1 (Referrals for Credible Allegations of Fraud) of the Agreement.

• If MFEAD accepts the matter and brings a civil or criminal charge against the provider which results

in a recovery, 7.27.12 of the Agreement shall apply.

19.3. Suspension of Medicaid Payments for Credible Allegations of Fraud

All providers are required to comply with PPACA's program integrity requirements and its corresponding

Federal regulations. This includes 42 CFR 455.23 which requires payment suspension of pending

investigations when the OIG has verified, on a case-by-case basis, that there is a credible allegation of

fraud. In addition to the requirements set forth in 7.27.11 (Referrals for Credible Allegations of Fraud) of

the Agreement:

• The OIG will provide written notice of provider payment suspension, in whole or in part, as follows:

o Notice to MFEAD;

o Notice to the MCO to impose suspension of payments to the provider; and

o Notice to the provider within five calendar days, or 30 calendar days if requested by law

enforcement, in writing requesting a delay in sending the notice.

▪ Law enforcement’s request to delay sending notice may be renewed in writing up to twice

and in no event may exceed 90 days.

▪ In such instances, the PIU will notify the MCOs in writing that an initial delay has been

requested and when 20 calendar days after law enforcement's request has been rescinded

or the 90 days has passed, advise the MCOs whether payment suspension should be

imposed in whole or in part.

Section 19: Program Integrity

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Effective date: January 1, 2019

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• The MCO shall adjudicate the provider's suspended claims as part of their regular course of business

and track the total amount(s) suspended. These amounts shall be reported to the PIU quarterly and

updated through ad hoc reporting, as requested.

• The MCO shall continue the suspension of payments, in whole or in part, until further notified in

writing by the PIU to release suspended funds. Release of funds will be authorized when law

enforcement agencies, such as MFEAD, determine that there is insufficient evidence of fraud by the

provider; or legal proceedings, to include any type of administrative or civil action, either by MFEAD

or HSD, related to the provider's alleged fraud are completed. The MCO shall release funds as

directed within 10 business days of the date of release authorization.

19.4. Adverse Action Reporting

Federal regulations, specifically 42 CFR 1002.3(b)(3) requires a state to report all adverse actions taken

on provider applications in the Medicaid program directly to the Federal Department of Health and

Human Services, Office of Inspector General (DHHS/OIG). Adverse actions that must be reported include

a denial of credentialing or enrollment of a provider when the denial is due to concerns other than

fraud, such as integrity or quality, or termination. For entities that are not natural persons, the

information required includes those individuals that have control of, ownership interest in, or managing

employees of the business entity. Examples of conduct that would constitute reporting to HSD (the PIU

and the MAD) include providers that are denied enrollment or termination:

• As a result of adverse licensure actions, e.g., providers who are reported to the Medicare Exclusion

Database, DHHS/OIG/General List of Excluded Individual Entities;

• Due to the engagement of fraudulent conduct;

• Due to abuse of billing privileges (e.g., billing for services not rendered or unnecessary Medical

services);

• Due to misuse of their Medicaid provider billing number;

• Due to falsification of information on enrollment application or information submitted to maintain

enrollment;

• Due to continued billing after suspension or revocation of the provider's professional licensure or

certification;

• Based on a State and/or Federal exclusion; or

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• Due to falsification of medical records which support services billed to Medicaid.

The MCO is directed to notify the PIU Manager and the MAD Provider Enrollment unit in writing of

identified provider adverse actions within five business days from the date the adverse action was

taken. An email is acceptable.

The MCO is required to develop policies and procedures for reporting all adverse actions taken on

provider applications in accordance with this provision and in accordance with HSD's requirements set

forth in 42 CFR 1002.3(b)(3).

The MCO is required to document and report all adverse actions taken on providers on Report 56

pursuant to the "Centennial Care Reporting Instructions Program Integrity-Report #56".

19.5. Recipient Explanation of Medical Benefits

The MCO is required to develop and implement policies and procedures for verifying with managed care

beneficiaries whether billed services were received through Recipient Explanation of Medical Benefits’

correspondence verification process and procedures as set forth in 42 CFR 455.20.

19.6. Fraud, Waste and Abuse Compliance Plan

The MCO is required to have a written Fraud, Waste and Abuse Compliance Plan ("Compliance Plan")

per 4.17.3 of the Agreement. The Compliance Plan must contain procedures designed to detect and

prevent fraud, waste and abuse in the administration and delivery of services under the Agreement. The

Compliance Plan is due to the PIU on July 1 of every State fiscal year. In addition to what is stated in the

Agreement, the Compliance Plan must also contain:

• Written policies and procedures that supports the execution of the Compliance Plan to prevent and

detect fraud, waste and abuse in the administration and delivery of services under the Centennial

Care Program;

• Designate a Compliance Officer and Compliance Committee;

• Training and Education of the MCO's employees, contractors, and providers;

• Auditing and Monitoring;

• Responding to identified or alleged potential fraud and suspicious activities; and

• Whistleblower protection and non-retaliation policy.

Section 20: Pharmacy

Revision dates: October 1, 2020

Effective dates: January 1, 2019

389 | P a g e

20. Pharmacy

20.1. General Information

Pharmacy Benefits: Centennial Care Programs

Prescription drugs are a benefit under the Centennial Care program to be covered by the MCOs. MCOs

shall support HSD in promptly responding to public and legislative inquiries involving the design and

management of the MCO’s pharmacy benefit.

Preferred Drug List (PDL) and Formulary Requirements

MCOs shall comply with the NMAC 8.308.9.14 Pharmacy Services and the Pharmacy Services section of

the Agreement.

Treatment Guidance for Chronic HCV Infection

MCOs shall establish a system to cover treatment of members over the age of 17 years old with active

Hepatitis C infection for the appropriate amount of time that the therapy requires for the member’s

diagnosis. The system will consist of:

• The approval process of properly requested treatments for members with chronic HCV infection

using the Uniform New Mexico HCV Checklist for Centennial Care (See MAD 634 Attached);

• The development of a provider incentive plan to expand the number of practitioners treating HCV in

New Mexico, including:

o Incentive(s) to receive training in the treatment of chronic HCV infection;

o Incentive(s) to begin treating such patients; and

o Incentives for treatment of each patient;

• Not using active alcohol or drug use as screening criteria for the treatment, approval or denial

process;

• Not using the specialty of the requesting provider as screening criteria for treatment, approval or

denial;

• Referral of all members to a community health worker, Care Coordinator, or MCO specialty

pharmacist at the time of a drug treatment request for guidance and treatment compliance;

• Quarterly data submission concerning number of requests, approvals, and denials by fibrosis stage

(or equivalent) and genotype for all treatment requests;

• A comprehensive plan of outreach to the MCOs’ referring providers requesting oral drug treatment

for chronic HCV-infected patients;

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Effective dates: January 1, 2019

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• A comprehensive plan to expand HCV case finding efforts and screening efforts; and

• A comprehensive plan to expand HCV screening efforts to conform to USPSTF/CDC/ American

Association for the Study of Liver Diseases (AASLD)/ Infectious Diseases Society of America (IDSA)

guidelines.

MCOs are to approve properly requested treatments for the following Centennial Care members with

chronic HCV infection:

• All members over age 17, all HCV genotypes, with a positive Hepatitis C RNA level;

• In all cases, the MCOs shall ensure (using the AASLD/IDSA guidelines) that each treatment request is

appropriate with respect to:

o HCV genotype and viral load;

o Drug dose(s) and duration(s). The MCO’s preferred formulary agent may be given preference if

the level of evidence and effectiveness (as measured by Systemic Vascular Resistance) is equal

or greater, and no drug interactions are of concern;

o The presence or absence of advanced fibrosis or cirrhosis. For the purpose of making treatment

decisions using the AASLD/IDSA guidance, "cirrhosis" can be considered to be present if any of

the following are present:

▪ APRI >= 1.0;

▪ Fib-4 >= 3.25;

▪ Transient Elastography Score>= 12.5 kP (F4 equivalent);

▪ Fibrotest > = 0.73 (F4 equivalent) OR Fibrometer with F4 predominance;

▪ Radiographic imaging or physical exam findings consistent with cirrhosis; and

▪ Liver biopsy confirming a METAVIR Score of F4.

o Prior HCV treatment experience:

▪ Plans may require resistance-associated substitutions testing, based on AASLD guidance.

• Guidance regarding lost or stolen medications:

o MCOs shall use the same criteria currently used for refills of other lost or stolen medications;

and

o MCOs shall use Care Coordination and other functions to minimize this occurrence.

• Guidance regarding requests for off-label, experimental, and other forms of treatment that are not

specified in the guidelines:

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Effective dates: January 1, 2019

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o MCOs shall initiate a peer to peer consultation with the requesting physician to further

understand the request and its rationale; and

o MCOs shall present the case to Project ECHO before issuing a denial.

• Note that a "properly requested treatment" as defined above means that:

o The Uniform Checklist form is completed fully as directed and submitted;

o Necessary lab data and copies of medical records are attached; and

o The requested drug(s), dose(s), and length of treatment are consistent with AASLD/IDSA

guidance as written (the level of evidence in the guidance should not be considered relevant to

length of treatment decisions). If not consistent, MCOs shall provide an appropriate alternative.

• MCOs are granted the option to expand their treatment criteria beyond these guidelines (e.g., to

those 17 years of age and under), with advance notice to and approval by MAD.

Community Pharmacy Reimbursement

• MCOs shall ensure that reimbursement to community-based pharmacies realistically reflect buying

power, buying volume, and price negotiating potential. MCOs must ensure that the Maximum

Allowed Cost (MAC) for ingredient cost generic drugs for community-based pharmacies is no lower

than the current National Average Drug Acquisition Cost (NADAC) listed for the NDC for the drug

item. The dispensing fees will be paid in accordance with the terms of the applicable pharmacies'

contracts.

Where there is no NADAC price available, such as for certain OTC drug items, certain generic drugs

that have few manufacturers, and some repackage products, the MAC must be no lower than the

published Wholesaler’s Average Cost (WAC) listed for the NDC plus 6%. The WAC must come from a

published national pharmacy pricing source such as Medispan or First Data Bank that is not

associated with the MCO or PBM. This pricing methodology for certain OTC drug items aligns with

the State's reimbursement structure under Medicaid FFS. Such pricing is in effect only for drug items

that do not have a NADAC price available.

If the pharmacy submits an ingredient cost less than NADAC (or the WAC plus 6% when applicable),

then the MCO's PBM may use that lower submitted amount as the ingredient cost.

o A community-based pharmacy is a pharmacy that has the following characteristics:

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▪ Is open to the public for prescriptions to be filled, regardless of the facility or practice where

the prescription was written. This includes multi-site pharmacy operations and franchises

whose locations are in New Mexico;

▪ Is located in New Mexico or near the state border, if the border town is a primary source of

prescription drugs for Centennial Care members residing in the border area;

▪ Is not government-owned, not hospital-owned or hospital-based, not an extension of a

hospital, not owned by a corporation owning hospitals, and not an extension of a medical

practice or specialty facility;

▪ Is not owned by a corporate chain with stores outside of New Mexico;

▪ Is not a mail order pharmacy; and

▪ Is not part of a national network of pharmacies or specialty pharmacies, including those

primarily used for supplying IV admixtures.

o A list of pharmacies to which this section of this policy applies is included at the end of this

policy. HSD develops and maintains the criteria for inclusion on the list and applies only to

community-based pharmacies that participate in the MCOs’ Centennial Care network. Inclusion

of a pharmacy on the list does not mandate inclusion of the pharmacy in the MCOs’ Centennial

Care network. This does not supersede any credentialing requirements established by the MCO

or its PBM. Pharmacies on the list that are not contracted for participation in the MCOs’

Centennial Care network will be subject to the MCOs’ out-of-network payment rules.

o The MCO is not obligated to adjust claims retroactively based on changes made by HSD/MAD to

the list.

• Calculation of Payment:

o A pharmacy cannot be required to submit a dispensing fee on the claim, nor shall the payer use

a submitted dispensing fee to limit payment. MCOs must ensure that the contracted dispensing

fee is used in the payment calculations including any applicable professional dispensing fees for

Community Based Pharmacies, as directed by HSD; and

o MCOs must pay for compounding fees when a pharmacist must prepare a compound

medication for a covered FDA approved drug/ingredient, for a dosage form or strength not

already commercially available, as written in a clinician’s prescription. Neither compounding

fees nor reimbursement will apply to a compound that includes non-covered pharmacy products

as defined by MAD regulations. MCOs must also pay HSD-required administration and incentive

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fees for pharmacist’s prescribing/consultation services, when the pharmacist is enrolled with

HSD, permitted by license, and credentialed by the MCO, such as may be done for vaccines,

smoking cessation products, combined hormonal and injectable contraceptives, and Naloxone.

When specifically established by MAD, MCOs will reimburse for administration fees for

injections, including but not limited to injectable vaccines and injectable contraceptives; and

MCOs will reimburse for the counseling fee for Naloxone, in all formulations/delivery methods.

Other counseling for FDA approved drugs, and products, as required by OBRA 90, is a

pharmacist’s dispensing responsibility.

• Updating Prices:

o NADAC prices (or WAC prices plus 6% for OTC drug items) must be implemented within seven

calendar days of NADAC price changes. If a price increase is not made within seven calendar

days, MCOs must ensure that pharmacy claims are adjusted to reflect the price increase for

claims that were not paid at the increased price. A price decrease cannot be implemented

retroactively.

o For MAC prices determined by an MCO (other than NADAC and WAC plus 6%), the MCO must

ensure all MAC payment levels are reviewed, at a minimum, once per week. If there is a price

increase that took place during the week that resets the MAC price, an increase must be

implemented within seven calendar days. If a price increase is not made within seven calendar

days, the MCO must ensure that paid pharmacy claims are adjusted to reflect the price increase,

if they were not paid at the increased price. A price decrease cannot be implemented

retroactively.

o MAC prices must be established by evaluation a range of prices from sources with prices

available in New Mexico. Documentation must be retained on how the price was selected and

how it was determined that the price was available in New Mexico. If an MCO selects the lowest

price available, documentation must be maintained showing that the source of the MAC price is

available from wholesalers in New Mexico. Short-term, special deal prices cannot be used to set

a MAC price at the lowest available price.

MCOs must cover flu shots, including the booster-enhanced flu shots for members when prescribed for

recipients 65 and older and for other conditions per CDC seasonal recommendations.

o MCOs must follow MAD direction regarding the minimum amount of information that must be

reported back to the pharmacy on a price challenge. When a MAC price challenge is made on

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the basis of failing to update a price within the applicable timeframes, and a pharmacy "wins"

the challenge, MCOs must ensure that all pharmacy claims that were underpaid, due to the lack

of a timely update, are adjusted.

o MCOs must require that if the pharmacy does not "win" the challenge, the response to the

pharmacy shall state: the drug price that is in effect on the date of service; the date that the

price was established as the MAC price; if the MAC price has subsequently changed since the

date of the prescription and the current MAC price; the basis of that price (i.e., how the price

was established); the NDC if the price is based on specific NDC; and how they concluded the

price was available in New Mexico.

o MCOs must accept the price challenges directly from the pharmacy if the MCO’s PBM is setting

the price unless the pharmacy contract with the Pharmacy Services Administration Organization

(PSAO) requires challenges to go through the PSAO, in which case the MCO must require the

PSAO to forward challenges to the MCO within three business days of receipt from the

pharmacy, and require the PSAO to forward any response to the pharmacy within three

business days of receipt from the MCO.

o For a claim recoupment or payment reduction made more than seven calendar days after initial

payment, a provider must be notified about the reason for the recoupment or reduction, the

amount of the recoupment or reduction, and given an opportunity to appeal or file a grievance.

There is no fair hearing right. This requirement does not apply if the pharmacy is reversing or

rebilling the claim that results in a recoupment or payment reduction.

o If the pharmacy contract with the PSAO requires that notice of payment recoupment or

reduction go through the PSAO, the MCO must require the PSAO to forward such notices

including language regarding the opportunity to appeal the pharmacy within three business days

of receipt from the MCO and the PSAO to forward any response to the MCO within three

business days of receipt from the pharmacy.

MCO Participation in the DUR Board and Submission of a DUR Annual Report

MCOs shall take part in a DUR program that complies with the requirements set forth in 42 C.F.R. §

438.3(s) and 42 CFR Part 456 Subpart K, and Section 1927(g) of the Social Security Act, to ensure

prescriptions are appropriate, medically necessary, and minimize the potential for adverse medical

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results. MCO representation on the DUR Board shall consist of one physician and one or two

pharmacists.

DUR Reporting Requirements:

MCOs are contractually responsible for providing outpatient drug benefits and for conducting utilization

review activities to promote the delivery of quality medically necessary care in a cost effective and

programmatically responsible manner. To ensure all areas of section 1927(g) of the Act are met, MCOs

must provide a detailed description of their DUR program activities to the State on an annual basis.

MCOs are required to take part in a DUR program and as part of this program, per CMS requirements,

each MCO will be required to submit a DUR report to HSD that will be submitted to CMS. The report

template is provided by CMS and at minimum shall contain the following:

• A description of the nature and scope of the prospective and retrospective drug review program;

• Detailed information on the specific criteria and standards in use;

• A summary of the educational interventions used and an assessment of the effect of these

• interventions on the quality of care; and

• An estimate of the cost savings generated as the result of the program.

For your reference, the following are links to the CMS website for previous DUR reports:

All States:

https://www.medicaid.gov/medicaid/prescription-drugs/drug-utilization-review/annual-reports/index.h

tml

New Mexico:

https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Prescription-Drugs/Downloa

ds/2016_New Mexico_DUR.pdf

MCO requirements regarding the Drug Rebate Analysis and Management System (DRAMS) and drug

rebate dispute resolution

HSD’s PBM will continue to send drug rebate invoices to manufacturers based on the encounter data for

pharmacy and medical claims submitted by the MCOs. HSD’s PBM will receive copies of the

manufacturers' checks. If the manufacturer does not pay the invoice in full because the manufacturer

disputes some of the data on the invoice, HSD’s PBM will refer the manufacturer dispute to the

appropriate MCO staff.

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Typically, when the manufacturer disputes the invoice based on incorrect data on the claims, the

manufacturer will request claim level detail (CLD). HSD’s PBM will send the CLD to the manufacturer.

After the manufacturer reviews the CLD, the manufacturer may issue a dispute in the form of an email

or letter, and request that the payer review the claims.

When a dispute is reported to the MCO, the MCO is responsible for reviewing their pharmacy claims

data to determine if the data needs to be corrected or if the data is correct. This entails reviewing claims

and possibly contacting pharmacy and medical providers to obtain information to resolve the dispute.

The MCO must report the resolution of the dispute to HSD’s PBM within 30 calendar days from the date

of receiving the notice of the dispute.

A smaller number of disputes are initiated after the manufacturer has already paid the invoice. These

disputes will be handled in the same manner as other disputes.

HSD’s PBM will review the MCO pharmacy and medical drug claims data prior to printing invoices in an

attempt to minimize disputes. Often, for specific drug items, reporting the correct number of units is a

common problem and the correction may be obvious to HSD’s PBM. In such cases it will make the

change prior to printing invoices. Usually, the problem occurs when the standard billing units differ from

the units that CMS expects to be used on the rebate invoices. A problem also may occur when an MCO

allows a provider to bill incorrect units. HSD’s PBM will notify an MCO of any situation where the MCO

continues to make the same error in data and the MCO will be required to implement corrections in

their processing of claims.

Common Dispute Reasons

Disputes frequently result from recurring circumstances and often for the same drug items each quarter.

When the error that will likely lead to a dispute originates with the provider and the MCO does not

detect the error when processing the claim, the MCO will be asked to correct their claims processing

editing to avoid continual disputes.

The following sections identify the most common reasons for disputes.

Unit Type Discrepancy

A provider bills a claim utilizing a unit type that differs from the unit type that was utilized in

calculating the rebate. Most claims processing systems allow providers to utilize only three unit types

when billing claims. Common claim processing system unit types:

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• Each (caps, tabs, kits, and vials)

• Milliliters (liquids)

• Grams (solids)

CMS has eight unit types for claims:

• AHF (refers only to injectable Anti-Hemophilic Factor units)

• CAP (capsule)

• SUP (suppository)

• GM (grams)

• ML (milliliter)

• TAB (tablet)

• TDP (transdermal patch)

• EA (each, refer to drugs not identifiable by any other unit type as given in program instructions)

Staff of HSD’s PBM will convert the common claims processing unit types before preparing manufacturer

invoices. If a dispute occurs based on unit conversion or for units that were not converted, HSD’s PBM

will make the correction in order to resolve the dispute.

If the unit type appears to be incorrect on the original encounter claim, the dispute will be sent to the

MCO DRAMS contact for resolution.

Data Entry Errors Regarding the Quantity

Incorrect quantities are sometimes entered on the claims by the provider. If the MCO does not detect

the incorrect quantities, this can cause discrepancies

with the number of units shown as dispensed on

the claim.

In resolving this type of dispute, the MCO DRAMS contact should review the claims data and determine

if the provider billed incorrectly. This will entail looking at the claim; contacting the provider and

requesting what the units represent (ML, GRAMS, and EACH). If it is an “each”, determine what the

“each” represents (CAP, TAB, kits or vials). If the claim was billed incorrectly, the provider must adjust

the claim with the correct units.

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Decimals

When the drug strength does not equal a whole number, or the units of measure or package size has a

decimal in the units, a decimal point in the units could mean a provider error.

If the MCO does not detect the incorrect quantities, this can cause discrepancies because use of a

decimal point may be illogical for many unit types for drug items.

In resolving this type of dispute, the MCO DRAMS contact should review the claims data in question and

determine if the provider likely billed incorrectly. It may be necessary to contact the provider if the units

are unusual and the MCO DRAMS contact cannot tell whether the provider's units are correct or

incorrect.

Units or Quantities Appear Inconsistent

If the units billed for a particular NDC are inconsistent with the number of prescriptions, the pharmacy

reimbursement or lowest dispensable package size, the drug manufacturers will question the amount

dispensed, if it appears to be an unexpected amount.

In resolving this type of dispute, the MCO DRAMS contact should review the claims data in question and

determine if the provider likely billed incorrectly. It may be necessary to contact the provider if the units

are unusual and the MCO DRAMS designate cannot tell whether the provider's units are correct or

incorrect.

Terminated/Invalid NDCs

Terminated NDCs (dispute code N) are those products where the shelf life for the last lot produced has

expired. Per CMS guidelines, the affected manufacturer or labeler is required to submit pricing data and

pay rebates for four quarters past the termination date, but only for claims with a date of service prior

to the termination date.

HSD’s PBM will contact the manufacturer to obtain the termination date and determine whether the

date has been provided to CMS. If advised that a termination date has been sent to CMS and a sufficient

amount of time has elapsed since that submission (two quarters), HSD’s PBM will provide the MCO

DRAMS contact staff with a list of the providers involved (i.e., those with the most claims for the drug

and quarter in question). The MCO DRAMS contact must notify the providers. If the provider has the

product on the shelf, they will need to provide the lot number and expiration date and provide the

information to staff of HSD’s PBM.

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Affected claims must be checked to identify all DOS that fall after the termination date. For those claims,

an adjustment must be made. The provider must adjust the claim if the incorrect NDC code was used.

State Units Exceed Expected Sales/No Record of Sales in the State

Manufacturers have a threshold on their NDC numbers and if they hit that threshold they will dispute

claims based on units exceed expected sales. They also will dispute if they show no record of sales of

their product within the state.

In resolving this type of dispute, the MCO DRAMS contact should determine if the provider used the

NDC code. Sometimes the provider can show they did order an item from out of state or have other

documentation that their billing was correct. The MCO must obtain documentation from the provider of

purchase, such as an invoice from their wholesaler with the NDC in question and the amount purchased.

This must be forwarded to HSD’s PBM so that it may provide the information to the drug manufacturer

when requested. The provider must adjust the claim, if the incorrect NDC code was used originally.

Inaccurate NDC

A pharmacy or medical provider may submit a claim in which the NDC billed is not the NDC dispensed. In

resolving this type of dispute, the MCO should contact the provider and determine if they really used

the NDC code reported.

The provider must adjust the claim if the incorrect NDC code was used.

Communicating with HSD’s PBM on Disputes and Correcting Errors

The MCO is to notify HSD’s PBM of claims on which the units were incorrect. HSD’s PBM will enter a

comment into DRAMS that the units were incorrect and that the MCO is working on adjustments. HSD’s

PBM will notify the manufacture regarding the status of the dispute.

HSD’s PBM cannot change the units on a claim, therefore, it is necessary for the MCO to have the

provider adjust the claim. When the encounter data is adjusted, the DRAMS system will back out the

incorrect quantity and issue new invoices with the new quantity as a prior quarter adjustment.

If the MCO verifies that some of the disputed quantities are correct, the MCO must notify HSD’s PBM.

HSD’s PBM will enter a comment into DRAMS that the units were correct and state how the quantity

was verified such as, a call to the provider. HSD’s PBM will notify the manufacturer. The manufacturer

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may request further documentation such as an invoice from the provider. When further documentation

is requested, HSD’s PBM will notify the MCO who will be responsible for obtaining the documentation.

MCO Compliance with the PBM Regulation Act

The MCO will ensure the PBMs are in compliance with the requirements outlined in the Pharmacy

Benefits Manager Regulation Act, NMSA 1978 § 59A-61. The MCOs shall ensure they are monitoring the

PBMs’ performance on an ongoing basis and the applicable requirements outlined in the Agreement

7.14: Major Subcontractors and Subcontractors are followed.

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21. Manual Acronyms

The following is a list of acronyms used throughout the document.

AAAHC Accreditation Association for Ambulatory Health Care

AASLD American Association for the Study of Liver Diseases

ABCB Agency Based Community Benefit

ABP Alternative Benefit Plan

ADHD Attention Deficit/Hyperactivity Disorder

ADL Activities of Daily Living

AHU Administrative Hearing Unit

ALJ Administrative Law Judge

ALTSD/ADRC Aging and Long-Term Services Department, Aging and Disability

Resource Center

APS Adult Protective Services

ARTC Accredited Residential Treatment Center

BH Behavioral Health

BHSD Behavioral Health Services Division

BISF Brain Injury Services Fund

BLN Business Leadership Network

BRCA Breast Cancer Susceptibility Gene

BSC Behavior Support Consultant

CAHPS Consumer Assessment of Healthcare Providers and Systems

CAP Corrective Action Plan

CB Community Benefit

CBC Criminal Background Check

CBMA Community Benefit Member Agreement

CBSQ Community Benefit Service Questionnaire

CCL Care Coordination Level

CCP Comprehensive Care Plan

CCU Care Coordination Unit

CDC U.S. Centers for Disease Control and Prevention

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CFR Code of Federal Regulations

CHR Community Health Representative

CHW Community Health Worker

CIA Client Individual Assessment

CIU Client Information Update

CLD Claim Level Detail

CNA Comprehensive Needs Assessment

COE Category of Eligibility

COR Consolidated Online Registry

COTA Certified Occupational Therapy Assistants

CPR Cardiopulmonary Resuscitation

CPS Child Protective Services

CRI Community Reintegration

CSA Core Service Agencies

CTA Community Transition Agency

CYFD New Mexico Children, Youth and Families Department

DD Developmentally Disabled

DDW Developmental Disabilities Waiver

DHHS/OIG U.S. Department of Health and Human Services, Office of

Inspector General

DHI Department of Health Improvement

DME Durable Medical Equipment

DMZ DMZ is short for DeMilitarized Zone and is software/web page

for the transmission and storage of data.

DOH/OSAH Department of Health’s, Office of School and Adolescent Health

DOS Dates of Service

DRAMS Drug Rebate Analysis and Management System

DSP Direct Support Professionals

DTE Difficult to Engage

DVR Division of Vocational Rehabilitation

DWS Department of Workforce Solutions

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EOB Explanation of Benefits

EOR Employer of Record

EPSDT Early Periodic Screening, Diagnostic, and Treatment

EQRO External Quality Review Organization

EVV Electronic Visit Verification

FFS Fee for Service

FHB Fair Hearings Bureau

FMA Financial Management Agency

FQHC Federally Qualified Health Center

FTP File Transfer Protocol

Geo/Access Geographical Access

HCBS Home and Community Based Services

HCV Hepatitis C Virus

HHA Home Health Agency

HHR/HRU High Health Risk/High Resource Utilization

HNF High Nursing Facility

HRA Health Risk Assessment

HSD New Mexico Human Services Department

I/T/U Indian Health Services, Tribal Health Providers, and Urban

Indian Providers

IADL Instrumental Activities of Daily Living

ICF IID Intermediate Care Facilities for Individuals with Intellectual

Disabilities

ID/RC Intellectual Disability/Related Condition

IDEA Individuals with Disabilities Education Act

IDSA Infectious Diseases Society of America

IDT Interdisciplinary Team

IHS Indian Health Service

IPoC Individual Plan of Care

ISD Income Support Division

ISP Individual Service Plan

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JAN Job Accommodation Network

JCAHO Joint Commission on Accreditation of Healthcare Organizations

LISW Licensed Independent Social Worker

LMFT Licensed Marriage and Family Therapist

LMSW Licensed Master Social Worker

LNF Low Nursing Facility

LOC Level of Care

LOD Letter of Direction

LOI Letter of Interest

LPAT Licensed Practicing Art Therapist

LPC Licensed Professional Counselor

LPCC Licensed Professional Clinical Counselor

LPN Licensed Practical Nurse

LRI Legally Responsible Individual

LTC Long Term Care

LTSS Long Term Services and Supports

LTSSB Long Term Services and Supports Bureau

MAC Maximum Allowed Cost

MAD Medical Assistance Division

MCO Managed Care Organization

MCO/UR Managed Care Organization/Utilization Review

MDS Minimum Data Set

MF Medically Fragile

MFCMP Medically Fragile Case Management Program

MFEAD New Mexico Medicaid Fraud and Elder Abuse Division

MFW Medically Fragile Waiver

MH Mental Health

MMIS Medicaid Management Information System

MSDS Material Safety Data Sheets

NADAC National Average Drug Acquisition Cost

NCQA National Committee for Quality Assurance

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NF Nursing Facility

NMAC New Mexico Administrative Code

NMSA New Mexico Statute Annotated

NOA Notice of Allocation

NOME Not Otherwise Medicaid Eligible

NPI National Provider Identifier

OT Occupational Therapy

OTC Over the Counter

PASRR Preadmission Screening and Resident Review

PCMH Patient Centered Medical Home

PCO Planning Center Online

PCP Primary Care Physician/ Primary Care Provider

PCS Personal Care Services

PDL Preferred Drug List

PFOC Primary Freedom of Choice

PH Physical Health

PHI Protected Health Information

PIPs Performance Improvement Projects

PIU Program Integrity Unit

POC Plan of Care

PPA Provider Participation Agreement

PPACA Patient Protection and Affordable Care Act

PRF Payment Request Form

PSA Prostate-Specific Antigen

PSAO Pharmacy Services Administration Organization

PT Physical Therapy

PTA Physical Therapy Assistants

QA Quality Assurance

QI Quality Improvement

RFA Request for Administrative Action

RFI Request for Information

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RHC Rural Health Clinic

RN Registered Nurse

RTM Return to Member

SB Support Broker

SDCB Self-Directed Community Benefit

SIER Self-Identified Error Resubmission

SIU Special Investigative Unit

SLP Speech Language Pathologist

SLT Speech and Language Therapy

SMEs Subject Matter Experts

SMI Serious Mental Illness

SNF Skilled Nursing Facility

SOC Setting of Care

SOE Summary of Evidence

SSI Supplemental Security Income

SSN Social Security Number

SSP Service and Support Plan

STI Sexually Transmitted Infection

SUD Substance Use Disorder

TB Tuberculosis

TBI Traumatic Brain Injury

TFC Therapeutic Foster Care

TPA Third Party Assessor

UB Universal Billing

UM Utilization Management

USPSTF United States Preventive Services Task Force

VAS Value Added Services

VBP Value Based Purchasing

WAC Wholesaler’s Average Cost