Current through Register Vol. 35, No. 18, September 24, 2024
A member who meets a NF LOC and who qualifies for MCO CB
must first access services through his or her MCO's ABCB approach. After 120
calendar days, the member may continue his or her CB services provided through
the MCO's ABCB or may select the MCO's SDCB approach. The member's MCO shall
obtain a signed statement from the member regarding his or her decision to
participate in the SDCB approach. The signed statement will include member
attestation that he or she understands the responsibilities of self-directing
his or her CB services, including the management of his or her care plan. For a
member transitioning from a NF: and the member continues to meet NF LOC; the
member selects his or her MCO's SDCB approach; the member must access CB
services through the MCO's ABCB approach for the first 120 calendar days of
eligibility; and after 120 calendar days, the member may transition to the
MCO's SDCB.
A. Self-assessment: The
member's care coordinator shall provide him or her with the MAD self-assessment
instrument. The self-assessment instrument shall be completed by the member
with assistance from the member's care coordinator upon request. The care
coordinator shall file the completed self-assessment in the member's
file.
B. Employer of record (EOR):
A member who is an unemancipated minor or has an authorized representative over
financial matters in place cannot serve as his or her own EOR. When the
member's care coordinator, based on the results of the member's
self-assessment, determines the member requires assistance to direct his or her
SDCB services, the member must designate in writing an EOR to assume the
functions on behalf of the member. A member that serves as his or her EOR has
the option to do so or may, on his or her own, designate a person to serve as
his or her EOR in writing. A designated EOR may not also be an employee of the
member. The member's file must have documentation of either the member acting
as his or her EOR or of the designated EOR. The member's MCO will make the
final determination on whether the member may be his or her own EOR.
C. Supports for self-direction: A member or
his or her authorized representative may designate a person to provide support
to the member's self-directed functions. The member or his or her authorized
representative may act as his or her EOR. A member's authorized representative
may function as the member's spokesperson. The member's care coordinator shall
include a copy of any EOR or spokesperson forms in the member's file and
provide copies to the member, the member's authorized representative,
spokesperson and the FMA.
(1) Care
coordination for self-direction: The MCO shall ensure that the member or the
member's authorized representative fully participates in developing and
administering SDCB services and that sufficient supports, such as care
coordinators and support brokers, are made available to assist the member or
the member's authorized representative who requests or requires assistance. In
this capacity, the care coordinator shall fulfill, in addition to contractual
requirement, the following tasks:
(a)
understand member and EOR roles and responsibilities;
(b) identify resources outside the member's
MCO SDCB, including natural and informal supports, that may assist in meeting
the member's long term care needs;
(c) understand the array of SDCB
services;
(d) assign the annual
SDCB budget based on the member's CNA to address the needs of the
member;
(e) monitor utilization of
SDCB services on a regular basis;
(f) conduct employer-related activities such
as assisting a member in identifying a designated EOR as appropriate;
(g) identify and resolve issues related to
the implementation of the member's SDCB care plan;
(h) assist the member with quality assurance
activities to ensure implementation of the member's SDCB care plan and
utilization of his or her authorized budget;
(i) recognize and report critical incidents,
including abuse, neglect, exploitation, emergency services, law enforcement
involvement, and environmental hazards;
(j) monitor quality of services provided by
the member's support broker; and
(k) work with the member to provide the
necessary assistance for successful SDCB implementation.
(2) A support broker is a qualified vendor
for a SDCB member who is either employed by or contracted by the member's MCO.
At a minimum, the support broker shall perform the following functions:
(a) educate the member on how to use
self-directed supports and services and provide information on program changes
or updates;
(b) review, monitor and
document progress of the member's SDCB care plan;
(c) assist in managing budget expenditures,
complete and submit SDCB care plan and revisions;
(d) assist with employer functions such as
recruiting, hiring and supervising SDCB providers;
(e) assist with developing and approving job
descriptions for SDCB direct supports;
(f) assist with completing forms related to
the member's employees;
(g) assist
with approving timesheets, purchase orders or invoices for goods, obtain quotes
for services and goods, as well as identify and negotiate with
vendors;
(h) assist with problem
solving of an employee or vendor payment issue with the FMA and other
appropriate parties;
(i) facilitate
resolution of any disputes regarding payment to a provider for services
rendered;
(j) develop the care plan
for SDCB based on the member's budget amount as determined by the CNA;
and
(k) assist in completing all
documentation required by the FMA.
(3) The FMA acts as the intermediary between
the member and the member's MCO's payment system and assists the member or the
member's EOR with employer-related responsibilities. The FMA pays employees and
vendors based upon the member's approved SDCB care plan and budget. The FMA
assures member and program compliance with state and federal employment
requirements, monitors, and makes available to the member and MAD reports
related to utilization of services and budget expenditures. Based on the
member's approved individual care plan and budget, the FMA must:
(a) verify that the member is eligible for
SDCB services prior to making payment for services;
(b) receive and verify that all required
employee and vendor documentation and qualifications are in compliance with
applicable NMAC rules and the MAD MCO policy manual;
(c) establish an accounting for each member's
budget;
(d) process and pay
invoices for goods, services, and supports approved in the member's SDCB care
plan and supported by required documentation; and
(e) process all payroll functions on behalf
of the member and EOR including:
(i) collects
and processes timesheets of employees in accordance with the MAD approved
payment schedule;
(ii) processes
payroll, withholding, filing, and payment of applicable federal, state and
local employment-related taxes and insurance;
(iii) tracks and reports disbursements and
balances of the member's budget and provides a monthly report of expenditures
and budget status to the member and his or her support broker, and quarterly
and annual documentation of expenditures to MAD;
(iv) receives and verifies a provider's
agreement, including collecting required provider qualifications;
(v) monitors hours billed for services
provided and the total amounts billed for all goods and services during the
month;
(vi) answers inquiries from
the SDCB member and solves problems related to the FMA's responsibilities;
and
(vii) reports any concerns
related to the health and safety of the member or when the member is not
following his or her approved SDCB care plan to the MCO and MAD as
appropriate.
D. Budget: The member's MCO will determine
the maximum annual budget allotment based on the member's CNA. The member may
request a revision to the SDCB care plan and budget when a change in
circumstances warrants such revisions, such as a change in health condition or
loss of natural supports. All changes are subject to assessment and approval by
the MCO.
E. SDCB care plan: The
support broker and the member shall work together to develop an annual SDCB
care plan for the SDCB services the member is identified to need as a result of
his or her CNA. The SDCB care plan will not exceed the MCO determined budget.
The support broker and member shall refer to the rates specified by HSD in
selecting payment rates for qualified providers and vendors. The care plan for
SDCB services shall be based upon the member's assessed needs and approved by
the member's MCO. The support broker shall closely monitor the utilization of
SDCB care plan services to ensure that the member does not exceed the approved
annual budget.
(1) SDCB care plan review
criteria: Services and goods identified in the member's requested SDCB care
plan may be considered for approval by the MCO if all of the following
requirements are met:
(a) the services or
goods must be responsive to the member's qualifying condition or
disability;
(b) the services or
goods must address the member's clinical, functional, medical or habilitative
needs;
(c) the services or goods
must facilitate the member's ADL per his or her CNA;
(d) the services or goods must promote the
member's personal health and safety;
(e) the services or goods must afford the
member an accommodation for greater independence;
(f) the services or goods must support the
member to remain in the community and reduce his or her risk for
institutionalization;
(g) the need
for the services or goods must be approved and documented in the CNA and
advance the desired outcomes in the member's SDCB care plan;
(h) the services or goods are not available
through another source;
(i) the
service or good is not prohibited by federal regulations, applicable NMAC
rules, supplements, the MAD MCO policy manual, service standards, and
instructions;
(j) the proposed rate
for each service is within the MAD approved rate range for that chosen
service;
(k) the proposed cost for
each good is reasonable, appropriate and reflects the lowest available cost for
that chosen good; and
(l) the
estimated cost of the service or good is specifically documented in the
member's SDCB care plan.
(2) SDCB care plan revisions: The SDCB care
plan may be revised based upon a change in the member's needs or circumstances,
such as a change in the member's health status or condition or a change in the
member's support system, such as the death or disabling condition of an
individual who was providing services. The member or the EOR is responsible for
assuring that all expenditures are in compliance with the most current
determination of need. SDCB care plan revisions involve requests to add new
goods or services to a care plan or to reallocate funds from any line item to
another approved line item. SDCB care plan revisions must be submitted to the
member's MCO for review and determination. Other than for critical health and
safety reasons, SDCB care plan revisions may not be submitted to the MCO for
review within the last 60 calendar days of the care plan year. Prior to
submitting a SDCB care plan revision request, the member is responsible for
communicating any utilization of services that are not in compliance with the
care plan to the support broker. At the MCO's discretion, a revision to the
SDCB care plan may require another CNA. If the SDCB care plan revision includes
a request for additional services, another CNA must be performed by the MCO to
determine whether the change in circumstance or need warrants additional
funding for additional services prior to SDCB care plan revision
approval.
F. SDCB back-up
plan: The support broker shall assist the member and his or her EOR in
developing a back-up plan for the member's SDCB services that identifies how
the member and EOR will address situations when a scheduled provider is not
available or fails to show up as scheduled. The member's support broker shall
assess the adequacy of the member's back-up plan at least on an annual basis
and when changes in the type, amount, duration, scope of the SDCB or the
schedule of needed services, or a change of providers (when such providers also
serve as back-up to other members) or change in availability of paid or unpaid
back-up providers to deliver needed care.
G. Member and EOR training: The member's MCO
shall require the member electing to enroll in the SDCB approach and his or her
EOR to receive relevant training. The support broker shall be responsible for
arranging for initial and ongoing training of the member and his or her EOR.
(1) At a minimum, self-direction training for
member and his or her EOR shall address the following issues:
(a) understanding the role of the member and
EOR with SDCB;
(b) understanding
the role of the care coordinator, support broker, the MCO, and the
FMA;
(c) selecting providers and
vendors;
(d) critical incident
reporting;
(e) member abuse and
neglect prevention and reporting;
(f) being an employer, evaluating provider
performance and managing providers;
(g) fraud and abuse prevention and
reporting;
(h) performing
administrative tasks, such as, reviewing and approving electronically captured
visit information and timesheets and invoices; and
(i) scheduling providers and back-up
planning.
(2) The
member's MCO shall arrange for ongoing training for the member and his or her
EOR upon request or if a support broker, through monitoring, determines that
additional training is warranted.
H. Claims submission and payment: The EOR
shall review and approve timesheets of the member's providers and invoices from
the member's vendors to determine accuracy and appropriateness. No SDCB
provider shall exceed 40 hours paid work in one work week per EOR. Timesheets
must be submitted and processed on a two-week pay schedule according to the
FMA's prescribed payroll payment schedule. The FMA shall be responsible for
processing the member's timesheets and invoices for approved SDCB services and
goods.
