New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 314 - LONG TERM CARE SERVICES - WAIVERS
Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER
Section 8.314.5.15 - DDW COVERED WAIVER SERVICES
Universal Citation: 8 NM Admin Code 8.314.5.15
Current through Register Vol. 35, No. 18, September 24, 2024
The DDW program is limited to the number of federally authorized unduplicated eligible recipient (UDR) positions and program funding. All DDW covered services in an ISP must be authorized by DOH. DDW services must be provided in accordance with all requirements set forth by DOH DDW service definition, all requirements outlined in the DDW service standards, and the applicable NMAC rules, supplements and guidance and must be based on assessed need. Services for individuals under the age of 21 must be coordinated with and shall not duplicate other services such as the medicaid school-based services program, the MAD early periodic screening diagnosis and treatment (EPSDT) program, or the early childhood education and care department (ECECD) family infant toddler (FIT) program. Services offered through the New Mexico public education department (PED), the Individuals with Disabilities Education Act (IDEA), the New Mexico division of vocational rehabilitation (DVR), the Rehabilitation Act, the Workforce Innovation and Opportunities Act (WIOA), the New Mexico department of workforce solutions (DWS) must be utilized prior to accessing funding from the DDW. DDW covers the following services for a specified and limited number of waiver eligible recipients as a cost effective alternative to institutionalization in an ICF-IID.
A. Information and documentation that justifies the need for services based on the eligible recipient's assessed need may be required and requested. Justification for services must:
(1) outline the eligible recipient's
clinical, functional, physical, behavioral or habilitative needs;
(2) promote and afford support to the
eligible recipient for their greater independence and to maintain current level
of function or minimize risk of further decline; or contribute to and support
the eligible recipient's efforts to remain in the community;
(3) to contribute and be engaged in their
community, and to reduce their risk of institutionalization;
(4) address the eligible recipient's physical
health, behavioral, and social support needs, not including financial support,
that arise as a result of their functional limitations or conditions, such as:
self-care, receptive and expressive language, learning, mobility,
self-direction, capacity for independent living, and economic self-sufficiency;
and
(5) relate to an outcome in the
eligible recipient's individual service plan (ISP).
B. Exception authorization process, formerly known as the H authorization process is the process that allows individuals on the DDW, who have extenuating circumstances, including extremely complex clinical needs to receive services beyond what is authorized in their current ISP/budget level or to allow individual exceptions to DDW service standards. Exception authorization process includes:
(1)
an eligible recipient who is included in the class established in the matter of
Walter Stephen Jackson, et al vs. Fort Stanton Hospital and Training School et.
al, (757 F. Supp. 1243 DNM 1990) is to receive a permanent NM DDW exception
authorization approval. A former Jackson class member may receive service types
and amounts consistent with those approved in their ISP.
(2) Exception authorization packet includes:
the completed individual supports needs review form with all attachments
indicated on the form as relevant to the nature/type of exception authorization
process request submitted.
C. When determining what services the eligible recipient needs, the IDT should consider the individual's service options with the understanding that the focus must always be on the individual's DDW support needs that can be clinically justified. Services available:
(1)
Case management
services: Case management services assist an eligible recipient to
access MAD covered services. A case manager also links the eligible recipient
to needed medical, social, educational and other services, regardless of
funding source. DDW services are intended to enhance, not replace existing
natural supports and other available community resources. Services will
emphasize and promote the use of natural and community supports to address the
eligible recipient's assessed needs in addition to paid supports. Case managers
facilitate and assist in assessment activities, as appropriate. Case management
services are person-centered and intended to advocate for and support an
eligible recipient in pursuing their desired life outcomes while gaining
independence, and access to services and supports. Case management is a set of
interrelated activities that are implemented in a collaborative manner
involving the active participation of the eligible recipient, their authorized
representative, and the entire IDT. The case manager is an advocate for the
eligible recipient they serve, is responsible for developing the ISP and for
ongoing monitoring of the provision of services included in the ISP. Case
management services include but are not limited to activities such as:
(a) assessing needs;
(b) assisting in the submission process of
the application for assistance and yearly recertification to the local income
support division (ISD) office;
(c)
directing the person-centered planning process;
(d) advocating on behalf of the eligible
recipient;
(e) coordinating waiver
and state plan service delivery and collaborating with managed care
organization care coordinators;
(f)
assuring services are delivered as described in the ISP;
(g) maintaining a complete current central
eligible recipient record (e.g. ISP, ISP budget, level of care documentation,
assessments);
(h) health care
coordination;
(i) assuring cost
containment by preventing the expense of DDW services from exceeding a maximum
cost established by DOH and by exploring other options to address expressed
needs.
(j) Case managers must:
(i) evaluate and monitor direct service
through face-to-face visits with the eligible recipient to ensure the health
and welfare of the eligible recipient, and to monitor the implementation of the
ISP;
(ii) support informed
choice;
(iii) support participant
self-advocacy;
(iv) allow
participants to lead their own meetings, program and plan
development;
(v) increase an
individual's experiences with other paid, unpaid, publicly-funded and community
support options;
(vi) increase
self-determination;
(vii)
demonstrate that the approved budget is not replacing other natural or non-
disability specific resources available; and
(viii) document efforts demonstrating choice
of non-waiver and non-disability specific options in the ISP, IDT meeting
minutes or companion documents when an individual has only DDW funded
supports.
(2)
Respite services: Respite services are a flexible family support
service for an eligible recipient. The primary purpose of respite services is
to provide support to the eligible recipient and give the primary, unpaid
caregiver relief and time away from their duties. Respite services include
assistance with routine activities of daily living (e.g., bathing, toileting,
preparing or assisting with meal preparation and eating), enhancing self-help
skills and providing opportunities for play and other recreational activities;
community and social awareness; providing opportunities for community and
neighborhood integration and involvement; and providing opportunities for the
eligible recipient to make their own choices with regard to daily activities.
Respite services will be scheduled as determined by the primary caregiver. An
eligible recipient receiving living supports or customized in-home supports
(when an eligible recipient is not living with a family member), may not access
respite services. Respite services may be provided in the eligible recipient's
own home, in a provider's home, or in a community setting of the eligible
recipient family's choice. Amounts and units of respite available per ISP year
to eligible recipients must comply with limits outlined in the DDSD issued
service standards. Respite services must be provided in accordance with
8.314.5.10 NMAC.
(3)
Adult nursing services:
Adult nursing services (ANS) are provided by a licensed RN or LPN under the
direct supervision of the RN to an eligible adult recipient. Adult nursing
services are intended to support the highest practicable level of health,
functioning and independence for an eligible recipient. This includes the
direct nursing services and activities related to the assessment, planning,
training and nursing oversight of unrelated direct support staff when assisting
with a variety of health related needs in specific settings. Nursing services
may be delivered in person and via remote or telehealth services. Nursing
services include an array of supports including efforts to support aspiration
risk management (ARM). Amounts and units of adult nursing services available
per ISP year to eligible recipients must comply with limits outlined in the
DDSD issued service standards. Nursing services may be delivered in person and
via remote or telehealth services. Individuals and their health care decision
makers will be informed of telehealth service and technology as part of the ISP
process.
(a) ANS is available to individuals
ages 21 and over who reside in family living; those who receive customized in
home supports and those who do not receive any living supports. It is available
to any eligible recipient who has health related needs that require at least
one of the following: nursing training, delegation or oversight of direct
support staff during participation in customized community supports (individual
or small group) or community integrated employment even if a living supports or
customized community supports (CCS) group are also provided.
(b) ANS is available to individuals ages
18-20 who reside in family living and who are at aspiration risk and desire to
have aspiration risk management services. It is also available to individuals
who have health related needs that require nursing training, delegation or the
oversight of non-related direct support staff during substitute care;
customized community supports (individual or small group); community integrated
employment or customized in home supports.
(c) There are two categories of adult nursing
services:
(i) assessment and consultation
services which includes a comprehensive health assessment (including assessment
for medication delivery needs and aspiration risk) and consultation regarding
available or mandatory services which requires only budgeting; and
(ii) ongoing services, which requires
clinical justification and are tied to the eligible recipient's specific health
needs revealed in the comprehensive health assessment and prior authorization
process.
(4)
Therapy services: Therapy services are to be delivered consistent
with the participatory approach philosophy and two models of therapy services
(collaborative-consultative and direct treatment). These models support and
emphasize increased participation, independence and community inclusion in
combination with health and safety. DDW therapy services are intended to
improve, maintain or minimize the decline in functional ability and skills.
Therapy services are designed to support achievement of ISP outcomes and
prioritized areas of need identified through therapeutic assessment. PT, OT and
SLP are skilled therapies that are recommended by an eligible recipient's IDT
members and a clinical assessment that demonstrates the need for therapy
services. Therapy services may be delivered in an integrated setting, clinical
setting, or through telehealth as appropriate and will support the use of
assistive or remote personal support technology as needed. Upon recommendation
for therapy assessment by the IDT members all three therapy disciplines: PT,
OT, and SLP will be available to all DDW recipients if the therapy assessment
indicates that services are needed. Individuals and their health care decision
makers will be informed of telehealth service and technology as part of the ISP
process. Therapy services for an eligible adult recipient require a prior
authorization except for their initial assessment. A RLD licensed practitioner,
as specified by applicable state laws and standards, provides the skilled
therapy services. Amounts and units of therapy services available per ISP year
to eligible recipients must comply with limits outlined in the DDSD issued
service standards. Therapy services for eligible adult recipients must comply
with 8.314.5.10 NMAC. All medically
necessary therapy services for children under 21 years of age, are covered
under the state plan through the early periodic screening, diagnostic and
treatment (EPSDT) and must comply with 8.320.2 NMAC. To the extent that any
listed services are covered under the state plan, the services under the waiver
are additional services not otherwise covered under the state plan, and
consistent with DDW objectives to support the recipient to remain in the
community and prevent institutionalization. The exception is aspiration risk
management supports for persons between age 18 and 21.
(a)
Physical therapy (PT): PT is
a skilled, RLD licensed therapy service involving the diagnosis and management
of movement dysfunction and the enhancement of physical and functional
abilities. Physical therapy addresses the restoration, maintenance, and
promotion of optimal physical function, wellness and quality of life related to
movement and health. Physical therapy prevents the onset, symptoms and
progression of impairments, functional limitations, and disability that may
result from diseases, disorders, conditions or injuries. PT supports access,
mobility and independence in all environments. A RLD licensed physical therapy
assistant (PTA) may perform physical therapy procedures and related tasks
pursuant to a plan of care/therapy intervention plan written by the supervising
physical therapist. Therapy services for eligible recipients must comply with
8.314.5.10 NMAC.
(b)
Occupational therapy (OT):
OT is a skilled, RLD licensed therapy service involving the use of everyday
life activities (occupations) for the purpose of evaluation, treatment, and
management of functional limitations. Therapy services for eligible recipients
must comply with
8.314.5.10 NMAC. Occupational
therapy addresses physical, cognitive, psychosocial, sensory, and other aspects
of performance in a variety of contexts to support engagement, performance and
access to work and life activities that affect health, well-being and quality
of life. A RLD certified occupational therapy assistant (COTA) may perform
occupational therapy procedures and related tasks pursuant to a therapy
intervention plan written by the supervising OT as allowed by RLD
licensure.
(c)
Speech-language pathology (SLP): SLP service, also known as speech
therapy, is a skilled therapy service, provided by a speech-language
pathologist that involves the non-medical application of principles, methods
and procedures for the diagnosis, counseling, and instruction related to the
development of and disorders of communication including speech, fluency, voice,
verbal and written language, auditory comprehension, cognition, swallowing
dysfunction and sensory-motor competencies. Therapy services for eligible
recipients must comply with
8.314.5.10 NMAC. Speech-language
pathology services are also used when an eligible recipient requires the use of
assistive technology or an augmentative communication device. For example, SLP
services are intended to improve, maintain or minimize the loss of
communication skills; treat a specific condition clinically related to an
intellectual developmental disability of the eligible recipient; or improve or
maintain the eligible recipient's ability to safely eat food, drink liquids or
manage oral secretions while minimizing the risk of aspiration or other
potential injuries or illness related to swallowing
disorders.
(5)
Living supports: Living supports are residential habilitation
services, available up to 24 hours a day, that are individually tailored to
assist an eligible recipient 18 year and older who is assessed to need daily
support or supervision with the acquisition, retention, or improvement of
skills related to living in the community to prevent institutionalization.
Living supports include residential-type instruction intended to increase and
promote independence and to support an eligible recipient to live as
independently as possible in the community in a setting of their own choice.
Living support services assist and encourage an eligible recipient to grow and
develop, to gain autonomy, self-direct and pursue their own interests and
goals. Living supports includes support to individuals to access: healthcare,
dietary, nursing, therapy and behavior supports through telehealth and in
person appointments; generic and natural supports, standard utilities including
internet services, assistive and remote technology, transportation, employment,
and opportunities to establish or maintain meaningful relationships throughout
the community. Living supports providers are also required to coordinate and
collaborate with nursing, behavior support consultants, dieticians, therapists
and therapy assistants to implement plans including aspiration risk management
plans. Living supports providers are also required to coordinate and
collaborate with behavior support consultants to implement positive behavior
support plans. Living support providers take positive steps to protect and
promote the dignity, privacy, legal rights, autonomy and individuality of each
eligible recipient who receives services. Services promote inclusion in the
community and an eligible recipient is afforded the opportunity to be involved
in the community and actively participate using the same resources and doing
the same activities as other community members. Living supports providers are
responsible for providing an appropriate level of services and supports up to
24 hours per day, seven days per week. Room and board costs are reimbursed
through the eligible recipient's social security insurance (SSI) or other
personal accounts and cannot be paid through the DDW. Living support services
for eligible recipients must comply with
8.314.5.10 NMAC. Living supports
consists of family living, supported living, and intensive medical living as
follows.
(a)
Family living (FL):
Family living is intended for an eligible recipient who is assessed to need
residential habilitation to ensure health and safety while providing the
opportunity to live in a typical family setting. Family living is a residential
habilitation service that is intended to increase and promote independence and
to provide the skills necessary to prepare an eligible recipient to live on
their own in a non-residential setting. Family living services are designed to
address assessed needs and identified individual eligible recipient outcomes.
Family living is direct support and assistance that is provided to no more than
two eligible recipients with intellectual or developmental disabilities at a
time furnished by a natural or host family member, or companion who meets the
requirements and is approved to provide family living services in the eligible
recipient's home or the home of the family living direct support personnel. The
eligible recipient lives with the paid direct support personnel in the same
residence as the paid DSP. The FL provider agency is responsible for providing
nutritional services from a registered dietician or licensed nutritionist. All
FL providers must be adult nursing services (ANS) providers and deliver
budgeted nursing services including nursing assessment and on call. The
provider agency is responsible for up to 750 hours of substitute coverage for
the primary direct support personnel to receive sick leave and time off as
needed. An exception may be granted by DOH if three eligible recipients are in
the residence, but only two of the three are on the DDW and the arrangement is
approved by DOH based on the home study documenting the ability of the family
living provider to serve more than two eligible recipients in the residence; or
there is documentation that identifies the eligible recipients as siblings or
there is documentation of the longevity of a relationship (e.g., copies of
birth certificates or social history summary). Documentation shall include a
statement of justification from a social worker, psychologist, and any other
pertinent professionals working with the eligible recipients. Family living
services cannot be provided in conjunction with any other living supports
service, respite, or additional nutritional counseling accessed through the
person's budget. Family living provider must arrange transportation for all
medical appointments, household functions and activities, and to-and-from day
services and other meaningful community options. The family living services
provider agency shall complete all DOH requirements for approval of each direct
support personnel, including completion of an approved home study and training
prior to placement. After the initial home study, an updated home study shall
be completed annually. The home study must also be updated each time there is a
change in family composition or when the family moves to a new home or other
significant event. The content and procedures used by the provider agency to
conduct home studies shall be approved by DOH and must include assessment of
environmental safety.
(b)
Supported living (SL): Supported living is intended for an
eligible recipient who is assessed to need residential-type habilitation
support to ensure health and safety. Supported living is a living habilitation
support service that is intended to increase and promote independence and to
provide the skills necessary to prepare an eligible recipient to live on their
own in a non-residential setting. Supported living services are designed to
address assessed needs and identified individual eligible recipient outcomes.
The service is provided to two to four eligible recipients in a community
residence. Prior authorization is required from DOH for an eligible recipient
to receive this service when living alone. The SL provider agency is
responsible for providing nutritional services from a registered dietician or
licensed nutritionist based on the person's needs. All SL providers must
provide needed nursing services including on call based on the person's needs.
The SL provider must arrange transportation to all medical appointments,
household functions and activities, and to-and-from day services and other
meaningful community options. Supported living services cannot be provided in
conjunction with any other living supports service, respite, or additional
nutritional counseling assessed through the person's budget. Amounts and units
of supported living services available per ISP year to eligible recipients must
comply with limits outlined in the DDSD issued service standards. Levels of
service category are differentiated by medical or behavioral need.
(i) Non-ambulatory stipend requires
documentation verifying that the recipient is non-ambulatory.
(ii) Extraordinary behavior or medical
support services require documentation that demonstrate extraordinary
behavioral or medical support needs; need for enhanced or additional staffing
is required for health and safety assurances; or medical needs cannot be met in
a lower service category.
(iii) The
person's physical or medical condition may be characterized by one of the
following: life threatening condition characterized by frequent periods of
acute exacerbation that requires regular or frequent medical supervision or
physician treatment or consultation.
(c)
Intensive medical living
supports: An intensive medical living supports agency provides
residential-type supports for an eligible recipient in a supported living
environment who requires daily direct skilled nursing, in conjunction with
community living supports that promote health and assist the eligible recipient
to acquire, retain or improve skills necessary to live in the community and
prevent institutionalization, consistent with their ISP. An eligible recipient
must meet criteria for intensive medical living supports according to DDW
service definitions and DDW standards for this service and they require nursing
care, ongoing assessment, clinical oversight and health management that must be
provided directly by a MAD recognized RN or LPN, see
8.314.5.10 NMAC.
(i) These medical needs include: skilled
nursing interventions; delivery of treatment; monitoring for change of
condition; and adjustment of interventions and revision of services and plans
based on assessed clinical needs.
(ii) In addition to providing support to an
eligible recipient with chronic health conditions, intensive medical living
supports are available to an eligible recipient who meets a high level of
medical acuity and require short-term transitional support due to recent
illness or hospitalization. This service will afford the core living support
provider the time to update health status information and health care plans,
train staff on new or exacerbated conditions and assure that the home
environment is appropriate to meet the needs of the eligible recipient.
Short-term stay in this model may also be utilized by an eligible recipient who
meets the criteria that is living in a family setting when the family needs a
substantial break from providing direct service. Both types of short-term
placements require prior approval from DOH. In order to accommodate referrals
for short-term stays, each approved intensive medical living supports provider
must maintain at least one bed available for such short-term placements. If the
short-term stay bed is occupied, additional requests for short-term stay will
be referred to other providers of this service.
(iii) The intensive medical living supports
provider will be responsible for providing the appropriate level of supports,
24 hours per day seven days a week, including necessary levels of skilled
nursing based on assessed need of the eligible recipient. Daily nursing visits
are required; however, a RN or a LPN under a RN's supervision is not required
to be present in the home during periods of time when skilled nursing services
are not required or when an eligible recipient is out in the community. An
on-call RN or LPN, under the supervision of a RN must be available to staff
during periods when a RN or a LPN under a RN's supervision is not present.
Intensive medical living supports require supervision by a RN, and must comply
with 8.314.5.10 NMAC.
(iv) Direct support personnel will provide
services that include training and assistance with ADLs such as bathing,
dressing, grooming, oral care, eating, transferring, mobility and toileting.
These services also include training and assistance with instrumental
activities of daily living (IADL) including housework, meal preparation,
medication assistance, medication administration, shopping, and money
management.
(v) The intensive
medical living supports provider will be responsible for providing access to
customized community support and employment as outlined in the eligible
recipient's ISP. This includes any skilled nursing needed by the eligible
recipient to participate in customized community support and development and
employment services. The intensive medical living provider must arrange
transportation for all medical appointments, household functions and
activities, and to-and-from day services and other meaningful community
options.
(vi) Approval for
supported living intensive medical supports requires a IMLS parameter tool with
a score of 20 or above.
(vii)
Intensive medical living supports providers must comply with
8.314.5.10
NMAC.
(6)
Customized community supports (CCS): CCS consists of
individualized services and supports that enable an eligible recipient to
acquire, maintain, and improve opportunities for independence, community
integration and employment. Customized community supports services are designed
around the preferences and choices of each eligible recipient and offer skill
training and supports to include: adaptive skill development; adult educational
supports; citizenship skills; communication; social skills, socially
appropriate behaviors; self-advocacy, informed choice; community integration
and relationship building. This service provides the necessary support to
develop social networks with community organizations to increase the eligible
recipient's opportunity to expand valued social relationships and build
connections within communities. This service helps to promote
self-determination, increases independence and enhances the eligible
recipient's ability to interact with and contribute to their community.
Customized community supports are intended to be provided in the community to
the fullest extent possible. Customized community supports must not duplicate
services available through the New Mexico public education department or the
Individuals with Disabilities Education Act (IDEA). Amounts and units of CCS
available per ISP year to eligible recipients must comply with limits outlined
in the DDSD issued service standards.
(a)
Based on assessed needs, customized community supports services may include
personal support, nursing oversight, medication assistance or administration,
and integration of strategies in the therapy and healthcare plans into the
eligible recipient's daily activities.
(b) The customized community supports
provider may provide fiscal management for the payment of adult education
opportunities as determined necessary for the eligible recipient.
(c) Customized community supports services
may be provided regularly or intermittently based on the needs of the eligible
recipient and are provided during the day, evenings and weekends. Customized
community supports are not limited to specific hours or days of the week and
should be provided in alignment with the persons desired outcomes.
(d) Customized community supports may be
provided in a variety of settings to include the community, classroom, remotely
and at site-based locations, depending on the ISP and the particular type of
service chosen within CCS. Services provided in any location are required to
provide opportunities that lead to participation and inclusion in the community
or support the eligible recipient to increase their growth and
development.
(e) Pre-vocational and
vocational services are not covered under customized community
supports.
(f) Customized community
supports services must be provided in accordance with
8.314.5.10
NMAC.
(7)
Community
integrated employment (CIE): Community integrated employment is intended
to provide supports that result in jobs in the community which increase
economic independence, self-reliance, social connections, and the ability to
grow within a career. CIE consists of intensive, ongoing services that support
individuals to achieve competitive integrated employment or business ownership
who, because of their disabilities, might otherwise not be able to succeed
without supports to perform in a competitive work setting or own a business.
Community integrated employment results in employment alongside non-disabled
coworkers within the general workforce or in business ownership. This service
may also include small group employment including mobile work crews or
enclaves. An eligible recipient is supported to explore and seek opportunity
for career advancement through growth in wages, hours, experience or movement
from group to individual employment. Each of these activities is reflected in
individual career plans. Community integrated employment services must not
duplicate services offered through the New Mexico public education department
(PED), the Individuals with Disabilities Education Act (IDEA), the New Mexico
division of vocational rehabilitation (DVR), the Rehabilitation Act, New Mexico
department of workforce solutions (DWS), or the Workforce Innovation and
Opportunities Act (WIOA). Compensation shall comply with state and federal laws
including the Fair Labor Standards Act. DDW funds (e.g., the provider agency's
reimbursement) may not be used to pay the eligible recipient for work. CIE
services shall be provided based on the interests of the person and desired
outcomes listed in the ISP. Employment services are to be available 365 days a
year, 24 hours a day. Community integrated employment services must comply with
8.314.5.10 NMAC. Community
integrated employment consists of job development, self-employment, short term
job coaching, job maintenance, intensive community integrated employment and
group community integrated employment models. Requests from eligible recipients
for CIE Intensive services must include a letter of justification and the
eligibility recipient's work hours or proposed schedule.
(a) Job development services through the DDW
can only be accessed when services are not otherwise available to the
beneficiary under either special education and related services as defined in
the Individuals with Disabilities Education Act (IDEA) or vocational
rehabilitation services available to the individual through a program funded
under section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730). Job
development may include but is not limited to, activities to assist an
individual to plan for, accommodate, explore and obtain CIE. Requests to
utilize the DDW for job development must have prior written approval by
DDSD.
(b) Short term job coaching
services through the DDW can only be accessed when services are not otherwise
available to the beneficiary under either special education and related
services as defined in the Individuals with Disabilities Education Act (IDEA)
or vocational rehabilitation services available to the individual through a
program funded under section 110 of the Rehabilitation Act of 1973
(29 U.S.C.
730). Short term job coaching services may
include but are not limited to, activities to assist an individual to learn,
accommodate and perform work duties, and maintain employment. Requests to
utilize the DDW for short term job coaching must have prior written approval by
DDSD.
(c) Job maintenance is
intended to be used as the long-term supports once all available funding and
services through vocational rehabilitation or the educational systems has been
utilized. Job maintenance is provided on a one-to-one ratio. Job maintenance
services may include, but are not limited to, activities to assist the
individual to accommodate, maintain employment and career
advancement.
(d) Self-employment:
Services through the DDW can only be accessed when services are not otherwise
available to the beneficiary under either special education and related
services as defined in the Individuals with Disabilities Education Act (IDEA)
or vocational rehabilitation services available to the individual through a
program funded under section 110 of the Rehabilitation Act of 1973
(29 U.S.C.
730). Self-employment services are intended
to be used as the long-term supports once all available funding and services
through vocational rehabilitation or the educational systems have been
utilized. Self-employment does not preclude employment in the other models.
Self-employment may include but is not limited to development of a business
plan, conducting market analysis, and establishing and supporting the
infrastructure for a successful business.
(e) Intensive community integrated employment
(ICIE): Services for people who are working in an individual, community
integrated employment setting and require more than 40 hours of staff supports
per month to maintain their employment. ICIE is the same scope of services as
outlined in
8.314.5.10 NMAC.
(f) Group community integrated employment:
Group community integrated employment is when more than one eligible recipient
works in an integrated setting with staff supports on site. Regular and daily
contact with non-disabled coworkers or the public occurs. Group community
integrated employment services may include but are not limited to activities to
assist the individual to accommodate, maintain and advance from group to
individual employment.
(8)
Behavioral support consultation
services: The behavior support consultation supports the person's
successful achievement of vision-driven desired outcomes. Behavior support
consultation services identify behaviors that impact quality of life and
provide specific prevention and intervention strategies to manage and lessen
the risks these behaviors present. This service is provided by an authorized
behavior support consultant and includes a positive behavior supports
assessment and positive behavior support plan development; interdisciplinary
team (IDT) training and technical assistance; and monitoring of an individual's
behavioral support services. Services may be provided in person for training,
evaluation or monitoring and remotely via telehealth as needed. Amounts and
units of behavioral support consultation services available per ISP year to
eligible recipients must comply with limits outlined in the DDSD issued service
standards. Requests from eligible recipients for behavioral support services
with units over limits as outlined in the DDSD service standards will require
submission of positive behavioral support assessment, positive behavioral
support plan, behavioral crisis intervention plan, and PRN psychotropic
medication plan as applicable. Annual assessments require an in-person
interview or observation except when conducted during declared state or
national emergencies or pandemics. Behavioral support services include:
(a) Assessment of the person and their
environment, including barriers to independent functioning;
(b) Design and testing of strategies to
address concerns and build on strengths and skills for independence;
(c) Writing and training in the
implementation of plans in a way that the person and DSP can understand and
implement them.
(d) Behavioral
support consultation services must comply with
8.314.5.10 NMAC.
(9)
Nutritional counseling
services: Nutritional counseling services include the assessment,
evaluation, collaboration, planning, teaching, consultation and implementation
and monitoring of a nutritional plan and menu services that supports the
eligible recipient to attain or maintain the highest practicable level of
health. It may be provided by a registered/licensed dietician (RD/LD) or
licensed nutritionist (LN). This service may be delivered in person or via
telehealth. The RD/LD/LN is an active member of the IDT and addresses overall
nutritional needs, diet, tube feeding, weight loss or gain, wounds and a
variety complex medical or behavioral conditions that have or may impact the
persons overall health. These nutritional counseling services are in addition
to those nutritional or dietary services allowed in the eligible recipient's
medicaid state plan benefit, or other funding source. This service does not
include oral-motor skill development services, such as those services provided
by a speech pathologist. Nutritional counseling cannot be billed as a separate
service during the hours of living supports. Nutritional counseling services
must comply with
8.314.5.10 NMAC.
(10)
Environmental modification
services: Environmental modifications services include the purchasing
and installing of equipment or making physical adaptions to an eligible
recipient's residence that are necessary to ensure the health, welfare and
safety of the eligible recipient or enhance their access to the home
environment and increase their ability to act independently.
(a) Adaptations, installations and
modifications include:
(i) heating and cooling
adaptations;
(ii) fire safety
adaptations;
(iii) turnaround space
adaptations;
(iv) specialized
accessibility, safety adaptations or additions;
(v) installation of specialized electric and
plumbing systems to accommodate medical equipment and supplies;
(vi) installation of trapeze and mobility
tracks for home ceilings;
(vii)
installation of ramps;
(viii)
widening of doorways or hallways;
(ix) modification of bathroom facilities
(roll-in showers, sink, bathtub and toilet modification, water faucet controls,
floor urinals and bidet adaptations and plumbing);
(x) purchase or installation of air filtering
devices;
(xi) purchase or
installation of lifts or elevators;
(xii) purchase and installation of glass
substitute for windows and doors;
(xiii) purchase and installation of modified
switches, outlets or environmental controls for home devices; and
(xiv) purchase and installation of alarm and
alert systems or signaling devices.
(b) Excluded are those adaptations or
improvements to the home that are of general utility and are not of direct
medical or remedial benefit to the eligible recipient. Adaptations that add to
the total square footage of the home are excluded from this benefit except when
necessary to complete an adaptation (e.g., in order to improve entrance/egress
to an eligible recipient's residence or to configure a bathroom to accommodate
a wheelchair).
(c) Environmental
modification services must be provided in accordance with applicable federal,
state and local building codes.
(d)
Amounts and units of environmental modification services available per ISP year
to eligible recipients must comply with limits outlined in the DDSD issued
service standards. Requests from eligible recipients for environmental
modification services must include a brief description of work to be done,
itemized cost for equipment, materials, with a description and cost of labor
and the DDSD verification of benefit availability form.
(e) Environmental modification services must
comply with
8.314.5.10
NMAC.
(11)
Crisis
supports: Crisis supports are services that provide intensive supports
by appropriately trained staff to an eligible recipient experiencing a
behavioral or medical crisis either within the eligible recipient's present
residence or in an alternate residential setting. Crisis supports must be prior
authorized by the DDSD bureau of behavioral supports (BBS). Crisis support must
comply with
8.314.5.10 NMAC.
(a)
Crisis supports in the eligible
recipient's residence: These services provide crisis response staff to
assist in supporting and stabilizing the eligible recipient while also training
and mentoring staff or family members, who normally support the eligible
recipient, in order to remediate the crisis and minimize or prevent
recurrence.
(b)
Crisis
supports in an alternate residential setting: These services arrange an
alternative residential setting and provide crisis response staff to support
the eligible recipient in that setting, to stabilize and prepare the eligible
recipient to return home or to move into another permanent location. In
addition, staff will arrange to train and mentor staff or family members who
will support the eligible recipient long-term once the crisis has stabilized,
in order to minimize or prevent recurrence of the crisis.
(c) Crisis response staff will deliver such
support in a way that maintains the eligible recipient's normal routine to the
maximum extent possible. This includes support during attendance at employment
or customized community supports services, which may be billed on the same
dates and times of service as crisis supports.
(d) This service requires prior written
approval and referral from the bureau of behavioral support (BBS). Crisis
supports are designed to be a short-term response (two to 90 calendar
days).
(e) The timeline may exceed
90 calendar days under extraordinary circumstances, with approval from the BBS
in which case duration and intensity of the crisis intervention will be
assessed weekly by BBS staff.
(12)
Non-medical transportation:
Non-medical transportation services assists the eligible recipient in accessing
other waiver supports and non-waiver activities identified in their ISP.
Non-medical transportation enables the eligible recipient to gain physical
access to non-medical community services and resources promoting the eligible
recipient opportunity and responsibility in carrying out their ISP activities.
This service is to be considered only when transportation is not available
through the medicaid state plan or when other arrangements cannot be made.
Non-medical transportation includes mileage reimbursement and funding to
purchase a pass for public transportation for the eligible recipient.
Reimbursement is allowable for eligible ride share programs identified through
ISP. Amounts and units of non-medical transportation available per ISP year to
eligible recipients must comply with limits outlined in the DDSD issued service
standards. Non-medical transportation provider services must comply with
8.314.5.10 NMAC.
(13)
Supplemental dental care:
Supplemental DDW dental care services are provided for an eligible recipient
that requires routine oral health care more frequently than the coverage
provided under other MAP benefit plans. Supplemental dental care provides one
oral examination and one cleaning once every ISP year to an eligible recipient
for the purpose of preserving or maintaining oral health. The supplemental
dental care service must comply with
8.314.5.10 NMAC.
(14)
Assistive technology:
Assistive technology (AT) purchasing agent service is intended to support the
access of low tech devices that increase the eligible recipient's physical and
communicative participation in functional activities at home and in the
community. Items purchased through the assistive technology service assist the
eligible recipient to meet outcomes outlined in their ISP, increase functional
participation in employment, community activities, activities of daily living,
personal interactions, or leisure activities, or increase the eligible
recipient's safety during participation of the functional or leisure activity.
Amounts and units of assistive technology available to eligible recipients per
ISP year must comply with limits outlined in the DDSD issued service standards.
(a) The assistive technology service allows
an eligible recipient to purchase or obtain needed items to develop low-tech
augmentative communication, environmental access, mobility systems and other
functional assistive technology, not covered through the eligible recipient's
medicaid state plan benefits.
(b)
Assistive technology may be accessed through an approved waiver provider acting
as a purchasing agent for technology vendors whose products meet definition and
needs or directly through an approved technology provider who is the direct
vendor of the service and approved DDW Provider.
(c) Assistive technology must comply with
8.314.5.10
NMAC.
(15)
Independent living transition services: Independent living
transition services are one-time set-up expenses for an eligible recipient who
transitions from a 24 hour living supports setting into a home or apartment of
their own with intermittent support that allows them to live more independently
in the community. The service covers expenses associated with security deposits
that are required to obtain a lease on an apartment or home, set-up fees or
deposits for utilities (telephone, internet, electricity, heating, etc.), and
furnishings to establish safe and healthy living arrangements, such as a bed,
chair, dining table and chairs, eating utensils and food preparation items, and
a cell phone. The service also covers services necessary for the eligible
recipient's health and safety such as initial or one-time fees associated with
the cost of paying for pest control, allergen control or cleaning services
prior to occupancy. Requests from eligible recipients for independent living
transition services must include DDSD verification of eligibility form. Amounts
and units of independent living transition services available per ISP year to
eligible recipients must comply with limits outlined in the DDSD issued service
standards. Independent living transition services must comply with
8.314.5.10 NMAC.
(16)
Remote personal support
technology: Remote personal support technology is an electronic device
or monitoring system that supports individuals to be independent in the
community or in their place of residence with limited assistance or supervision
of paid staff. This service provides up to 24-hour alert, monitoring or remote
personal emergency response capability, remote prompting or in-home reminders,
or environmental controls for independence through the use of technologies. The
service is intended to promote independence and quality of life, to offer
opportunity to live safely and as independently as possible in one's home, and
to ensure the health and safety of the individual in services. Remote personal
support technology is available to individuals who may want to live
independently in their own homes, may have a demonstrated need for timely
response due to health or safety concerns, or may be afforded increased
independence from staff supervision in residential services. The use of
technology should ease life activities for individuals and their families.
Remote personal support technology includes development of individualized
response plans with the installation of the electronic device or sensors,
monthly maintenance, rental or subscription fees. This service is not intended
to provide for paid, in-person on-site response. On-site response must be
planned through response plans that are developed using natural or other paid
supports for on-site response. Remote personal support technology may be
accessed through an approved waiver provider acting as a purchasing agent for
technology vendors whose products meet definition and needs or directly through
an approved technology provider who is the direct vendor of the service and
approved DDW provider. Amounts and units of remote support technology available
per ISP year to eligible recipients must comply with limits outlined in the
DDSD issued service standards.
(17)
Preliminary risk screening and consultation related to inappropriate
sexual behavior (PRSC): PRSC is designed to assess continued risk of
sexually inappropriate or offending behavior in persons who exhibit or have a
history of exhibiting risk factors for these types of behaviors. This service
is part of a variety of behavior support services (including BSC and
socialization & sexuality education) that promotes community safety and
reduces the impact of interfering behaviors that compromise the person's
quality of life. PRSC is provided by a licensed mental health professional who
has been trained and approved as a risk evaluator by the BBS. Amounts and units
of PRSC available per ISP year to eligible recipients must comply with limits
outlined in the DDSD issued service standards.
(a) The key functions of PRSC are to:
(i) provide a structured screening of the
eligible recipient's behaviors that may be sexually inappropriate;
(ii) develop and document recommendations of
the eligible recipient in the form of a report or consultation notes;
(iii) develop and periodically review risk
management plans for the eligible recipient, when recommended; and
(iv) provide consultation regarding the
management and reduction of the eligible recipient's sexually inappropriate
behavioral incidents that may pose a health and safety risk to the eligible
recipient or others.
(b)
Preliminary risk screening and consultation related to inappropriate sexual
behavioral services must comply with
8.314.5.10
NMAC.
(18)
Socialization and sexuality education (SSE) service: Socialization
and sexuality education in the form of the friends & relationships course
(FRC) is a comprehensive lifelong adult education program that teaches students
knowledge and skills to increase social networks with healthy, meaningful
relationships and to increase personal safety including decreasing
interpersonal and intimate violence in relationships, sexual victimization,
exploitation and abuse. This enhances their ability to develop close
friendships and romantic relationships. The FRC involves the person's network
of support (natural supports, paid supports, teachers, nurses, family members,
guardians, friends, advocates, or other professionals) teaching them to support
the social and sexual lives of persons with I/DD, through participation in
classes, and by using trained and paid self-advocates as role models and peer
mentors in classes. Amounts and units of SSE available per ISP year to eligible
recipients must comply with limits outlined in the DDSD issued service
standards. Socialization and sexuality education services must comply with
8.314.5.10 NMAC.
(19)
Customized in-home
supports: Customized in-home support services is not a residential
habilitation service and is intended for an eligible recipient that does not
require the level of support provided under living supports services.
Customized in-home supports provide an eligible recipient the opportunity to
design and manage the supports needed to live in their own home or family home.
Customized in-home supports include a combination of instruction and personal
support activities provided intermittently to assist the eligible recipient
with ADLs, meal preparation, household services, and money management. The
services and supports are individually designed to instruct or enhance home
living skills, community skills and to address health and safety of the
eligible recipient, as needed. This service provides assistance with the
acquisition, improvement or retention of skills that provides the necessary
support to achieve personal outcomes that enhance the eligible recipient's
ability to live independently in the community. Services are delivered by a
direct support professional in the individuals own home or family home in the
community. Services may be provided as part of on-site response plan with use
of remote personal support technology. This service is intended to provide
intermittent support and cannot be provided 24 hours a day/seven days a week.
Requests for customized in-home living supports for over 11 hours a day must be
approved the DDSD. Customized in-home support services must comply with
8.314.5.10
NMAC.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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