Current through Register Vol. 35, No. 18, September 24, 2024
A.
Requirements for individual employees, independent providers, provider
agencies and vendors: In order to be approved as an individual employee,
an independent provider, including non-licensed homemaker or direct support
worker, a provider agency, (excluding consultant providers which are covered in
a different subsection) or a vendor, including those that provide professional
services, each individual or entity must meet the general and service specific
qualifications set forth in this rule initially and continually meet licensure
requirements as applicable, and submit an employee or vendor enrollment packet,
specific to the provider or vendor type, for approval to the FMA. The provider
agency is responsible to ensure that all agency employees meet the required
qualifications. In order to be an authorized provider for the mi via program
and receive payment for delivered services, the provider must complete and sign
an employee or vendor provider agreement and all required tax documents.
Individual employees may not provide more than 40 hours of services in a
consecutive seven-day work week. The provider must have credentials verified by
the eligible recipient or the EOR and the FMA.
(1) Prior to rendering services to an
eligible mi via recipient as an independent contractor for homemaker or direct
support worker, respite, community direct support, employment supports, and
in-home living support provider, an individual seeking to provide these
services must complete and submit a nature of services questionnaire to the
FMA. The FMA will determine, based on the nature of services questionnaire if
the relationship is that of an employee or an independent contractor.
(2) An authorized consultant
provider must have a MAD approved provider participation agreement (PPA) and
the appropriate approved DOH developmental disabilities division (DDSD)
agreement.
B.
General qualifications:
(1)
Individual employees, independent providers, including non-licensed
homemaker/direct support workers who are employed by a mi via eligible
recipient to provide direct services shall:
(a) be at least 18 years of age;
(b) be qualified to perform the service and
demonstrate capacity to perform required tasks;
(c) be able to communicate successfully with
the eligible recipient;
(d) prior
to the initial hire and every three years after initial hire pass a nationwide
caregiver criminal history screening pursuant to Section
29-17-2 et seq.,
NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section
27-7a-1 et
seq., NMSA 1978 and 8.11.6 NMAC; additionally employees must pass the employee
abuse registry (EAR) pursuant to 7.1.12 NMAC, certified nurse aide registry
pursuant to 16-12.20 NMAC, office of inspector exclusion list pursuant to
section 1128B(f) of the Social Security Act; and the national sex offender
registry pursuant to 6201 as federal authority for active programs.
(e) complete training on critical incident,
abuse, neglect, and exploitation reporting;
(f) complete training specific to the
eligible recipient's needs; an assessment of training needs is determined by
the eligible recipient or his or her authorized representative; the eligible
recipient 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 eligible recipient's AAB; and
(g) meet any other service specific
qualifications, as specified in this rule and its service standards.
(2) Vendors, including those
providing professional services shall meet the following qualifications:
(a) shall be qualified to provide the
service;
(b) shall possess a valid
business license, if applicable;
(c) meet financial solvency, maintain and
adhere to training requirements, record management, quality assurance policy
and procedures, if applicable;
(d)
be in good standing with and comply with his or her New Mexico practice board
or other certification or licensing required to render mi via services in New
Mexico; and
(e) must not have a DOH
current adverse action against them.
(f) assure that employees of the vendor:
(i) are at least 18 years of age;
(ii) are qualified to perform the service and
demonstrate capacity to perform required tasks;
(iii) are able to communicate successfully
with the eligible recipient;
(iv)
pass a nationwide caregiver criminal history screening pursuant to Section
29-17-2 et seq.,
NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section
27-7a-1 et
seq., NMSA 1978 and 8.11.6 NMAC;
(v) complete training on critical incident,
abuse, neglect, and exploitation reporting;
(vi) complete training specific to the
eligible recipient's needs; an assessment of training needs is determined by
the eligible recipient or his or her authorized representative; the eligible
recipient 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 eligible recipient's AAB; and
(g) meet any other service specific
qualifications, as specified in this rule and its service standards.
(3) Qualified and approved
relatives, authorized representatives or personal representatives may be hired
as employees and paid for the provision of mi via services (except consultant
and support guides, customized community group supports services,
transportation services for a minor, and individual directed goods and
services). The services must be identified in the eligible recipient's approved
SSP and AAB, and the EOR is responsible for verifying that services have been
rendered by completing, signing, and submitting documentation, including the
timesheet, to the FMA. These services must be provided within the limits of the
approved SSP and AAB and may not be paid in excess of 40 hours in a consecutive
seven-day work week. LRIs, authorized representatives, personal representatives
or relatives may not be both a paid employee for the eligible recipient and
serve as the eligible recipient's EOR. An authorized or personal representative
who is also an employee may not approve his or her own timesheet.
(4) A LRI may be hired and paid for provision
of mi via services (except transportation services when requested for a minor,
a consultant and support guide, and customized community group supports
services, and related goods) under extraordinary circumstances in order to
assure the health and welfare of the eligible recipient and to avoid
institutionalization when approved by DOH. MAD must be able to receive federal
financial participation (FFP) for the services.
(a) Extraordinary circumstances include the
inability of the LRI to find other qualified, suitable caregivers when the LRI
would otherwise be absent from the home and, thus, the caregiver must stay at
home to ensure the eligible recipient's health and safety.
(b) 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.
(c) Services provided by LRIs must:
(i) meet the definition of a service or
support and be specified in the eligible recipient's approved SSP and
AAB;
(ii) be provided by a parent
or spouse who meets the provider qualifications and training standards
specified in the mi via rule for that service; and
(iii) be paid at a rate that does not exceed
that which would otherwise be paid to a provider of a similar service, and be
approved by the TPA.
(d)
A LRI who is a service provider must comply with the following:
(i) a parent, parents in combination, legal
guardian of a minor, or a spouse of the eligible recipient, may not provide
more than 40 hours of services in a consecutive seven-day work week; for
parents or legal guardians of the eligible recipient, 40 hours is the total
amount of service regardless of the number of eligible recipients under the age
of 21 who receive services through the mi via program;
(ii) planned work schedules must be
identified in the approved SSP and AAB, and variations to the schedule must be
reported to the eligible recipient's consultant and noted and supplied to the
FMA when billing; and
(iii)
timesheets and other required documentation must be maintained and submitted to
the FMA for hours paid.
(e) An eligible recipient must be offered a
choice of providers. There must be written approval from DOH when a provider is
chosen who is:
(i) a parent or legal guardian
of an eligible recipient who is a minor; or
(ii) the eligible recipient's
spouse.
(f) This written
approval must be documented in the SSP.
(g) The FMA monitors, on a monthly basis,
hours billed for services provided by the LRI and the total amounts billed for
all goods and services during the month.
(5) Once enrolled, providers, vendors and
contractors receive a packet of information from the eligible recipient or FMA,
including billing instructions, and other pertinent materials. Mi via eligible
recipients or EOR's or authorized representatives are responsible for ensuring
that providers, vendors and contractors have received these materials and for
updating them as new materials are received from MAD and DOH. MAD makes
available on its website, and in hard copy format, information necessary to
participate in medical assistance programs administered by HSD or its
authorized agents, including program rules, billing instructions, utilization
review instructions, and other pertinent materials. DOH makes available on its
website information, instructions and guidance on its administrative
requirements for the mi via program. When enrolled, an eligible recipient or
his or her authorized representative, or the provider, vendor or contractor
receives instruction on how to access these documents. It is the responsibility
of the eligible recipient or authorized representative, or the provider,
vendor, or contractor to access these instructions or ask for paper copies to
be provided, to understand the information provided and to comply with the
requirements. The eligible recipient or authorized representative, or the
provider, vendor, or contractor must contact HSD or its authorized agents to
request hard copies of any program rules manuals, billing and utilization
review instructions, and other pertinent materials and to obtain answers to
questions on or not covered by these materials.
(a) No employee of any type may be paid in
excess of 40 hours within the established consecutive seven day work week for
any one eligible recipient or EOR.
(b) No provider agency is permitted to
perform both LOC assessments and provide any services for the eligible
recipients.
(c) Providers may
market their services, but are prohibited from soliciting eligible recipients
under any circumstances such as offering an eligible recipient or his or her
authorized representative gratuities in the form of entertainment, gifts,
financial compensation to alter that eligible recipient's selection of provider
agencies, service agreements, medication, supplies, goods or
services.
(d) Those signing a
payment request form for vendor services rendered to an eligible recipient may
not serve as an employee, contractor or subcontractor of that vendor for that
eligible recipient. An eligible recipient who does not have an authorized
representative providing oversight of the eligible recipient's financial
matters may sign off on the payment request form.
(6) The EOR is the individual responsible for
directing the work of the eligible recipient's employees. An eligible recipient
is required to have an EOR when utilizing employees. The EOR may be the
eligible recipient or a designated qualified individual. A recipient through
the use of the mi via EOR questionnaire will determine if an individual meets
the requirements to serve as an EOR. The recipient's consultant will provide
him or her with the questionnaire. The questionnaire shall be completed by the
recipient with assistance from the consultant upon request. The consultant
shall maintain a copy of the completed questionnaire in the recipient's file.
When utilizing both vendors and employees, an EOR is required for oversight of
employees and to sign payment request forms for vendors. The EOR must be
documented with the FMA, whether the EOR is the eligible recipient or a
designated qualified individual. A POA or other legal instrument may not be
used to assign the EOR responsibilities, in part or in full, to another
individual and may not be used to circumvent the requirements of the EOR as
designated in 8.314.6 NMAC.
(a) An eligible
recipient that has a plenary or limited guardianship or conservatorship over
the eligible recipient's financial matters may not be his or her own EOR nor
sign payment vendor request forms for vendors.
(b) A person under the age of 18 years may
not be an EOR.
(c) An EOR who lives
outside New Mexico shall reside within 100 miles of the New Mexico state
border. Any out of state EOR residing beyond this radius who has been approved
prior to the effective date of this rule may continue to serve as the
EOR.
(d) The eligible recipient's
provider may not also be his or her EOR nor sign payment vendor request forms
for vendors.
(e) An EOR whose
performance compromises the health, safety or welfare of the eligible
recipient, may have his or her status as an EOR terminated.
(f) An EOR may not be paid for any other
services utilized by the eligible recipient for whom he or she is the EOR,
whether as an employee of the eligible recipient, a vendor, or an employee or
contactor, or subcontractor of an agency. An EOR makes important determinations
about what is in the best interest of the eligible recipient, and should not
have any conflict of interest. An EOR assists in the management of the eligible
recipient's budget and should have no personal benefit connected to the
services requested or approved on the budget.
(g) An EOR is not required if an eligible
recipient is utilizing only vendors for services; however, an EOR can be
identified by an eligible recipient to assist with the use of vendors. In some
instances an EOR for vendor services may be required by MAD. A recipient
utilizing vendors only who selects not to have an EOR will submit documentation
to the FMA identifying an authorized signer who will be responsible for signing
payment request forms. The authorized signer for vendor services rendered to an
eligible recipient may not serve as an employee, contractor or subcontractor of
that vendor for that eligible recipient. An eligible recipient who does not
have a plenary or limited guardianship or conservatorship providing oversight
of the eligible recipient's financial matters may be his or her own authorized
signer for the payment request form. A POA may not be used to assign the
responsibilities of the authorized signer, in part or in full, to another
individual and may not be used to circumvent the requirements of the authorized
signer as designated in this rule.
(h) An EOR, or authorized signer, is required
to complete and provide documents to the FMA according to the timelines and
rules established by the state. Documents include, but are not limited to:
vendor and employee enrollment agreements, vendor information forms, criminal
background check forms, timesheets, payment request forms, invoices, and other
documents needed by the FMA to enroll and process payment to employees and
vendors. The mi via program requires that employee timesheets be submitted
online unless the recipient has an approved exception from HSD.
C.
Service
specific qualifications for consultant services providers: In addition
to general requirements, a consultant provider shall ensure that all
individuals hired or contracted to provide consultant services meet the
criteria specified in this section and comply with all applicable NMAC MAD
rules and mi via service standards.
(1)
Consultant providers shall:
(a) possess a
minimum of a bachelor's degree in social work, psychology, human services,
counseling, nursing, special education or a closely related field, and have one
year of supervised experience working with people living with disabilities;
or
(b) have a minimum of six years
of direct experience related to the delivery of social services to people
living with disabilities; and
(c)
be employed by an enrolled mi via consultant provider agency; and
(d) complete all required mi via program
orientation and training courses; and
(e) be at least 21 years of age.
(2) Consultant providers may also
use non-professional staff to carry out support guide functions. Support guides
provide more intensive supports, as detailed in the service section of these
rules. Support guides help the eligible recipient more effectively self-direct
services when there is an identified need for this type of assistance.
Consultant providers shall ensure that non-professional support staff:
(a) are supervised by a qualified consultant
as specified in this rule;
(b) have
experience working with people living with disabilities;
(c) demonstrate the capacity to meet the
eligible recipient's assessed needs related to the implementation of the
SSP;
(d) possess knowledge of local
resources, community events, formal and informal community organizations and
networks;
(e) are able to
accommodate a varied, flexible and on-call type of work schedule in order to
meet the needs of the eligible recipient; and
(f) complete training on self-direction and
incident reporting; and
(g) be at
least 18 years of age.
D.
Service specific qualifications for
personal plan facilitation providers: In addition to general MAD
requirements, a personal plan facilitator agency must hold a current business
license, and meet financial solvency, training, records management, and quality
assurance rules and requirements. Personal plan facilitators must possess the
following qualifications in addition to the general qualifications:
(1) have at least one year of experience
working with persons with disabilities; and
(2) be trained and mentored in the planning
tool(s) used; and
(3) have at least
one year experience in providing the personal plan facilitation
service.
E.
Service specific qualification for living supports providers: In
addition to general MAD requirements, the following types of providers must
meet additional qualifications specific to the type of services provided.
(1)
Qualifications of homemaker direct
support service providers: Provider agencies must be homemaker agencies
certified by the MAD or its designee or a home health agency holding a New
Mexico home health agency license. A homemaker and home health agency must hold
a current business license when applicable, and meet financial solvency,
training, records management, and quality assurance rules and
requirements.
(2)
Qualifications of home health aide service providers: Home health
or homemaker agencies must hold a New Mexico current home health agency, rural
health clinic, or federally qualified health center license. Home health aides
must have successfully completed a home health aide training program, as
described in
42 CFR
484.36(a)(1) and (2) or have
successfully completed a home health aide training program pursuant to
7.28.2.30
NMAC. Home health aides must also be supervised by a registered nurse (RN)
licensed in New Mexico. Such supervision must occur at least once every 60
calendar days in the eligible recipient's home, and shall be in accordance with
the New Mexico Nurse Practice Act and be specific to the eligible recipient's
SSP.
(3)
Qualifications of
in-home living supports providers: Provider agencies must hold a current
business license, and meet financial solvency, training, records management,
and quality assurance rules and requirements. In-home living agency staff and
its direct staff rendering the service must have one year of experience working
with people with disabilities. In-home living support agencies must assure
appropriate staff for a 24 hour response capability to address scheduled or
unpredictable needs related to health, safety, or security in order to meet the
needs of the recipient. In-home living support agencies are not fiscal
intermediaries and cannot bill nor be paid for work that the recipient or EOR
are responsible for as required by Paragraph (6) of Subsection B of 8.314.6.11
NMAC and the mi via service standards.
F.
Service specific qualifications for
community membership support providers: In addition to general MAD
requirements, the following types of providers must meet additional
qualifications specific to the type of services provided. An agency providing
community membership services must hold a current business license, and meet
financial solvency, training, records management, and quality assurance rules
and requirements.
(1)
Qualifications of
supported employment providers:(a) A
job developer, whether an agency or individual provider, must:
(i) be at least 21 years of age;
(ii) pass criminal background check and abuse
registry screen;
(iii) have
experience developing and using job and task analyses;
(iv) have experience working with the
division of vocational rehabilitation (DVR), a traditional DD waiver employment
provider, an independent living center or other organization that provides
employment supports or services for people with disabilities and be trained on
the purposes, functions and general practices of entities such as the
department of workforce solutions navigators, one-stop career centers, business
leadership network, chamber of commerce, job accommodation network, small
business development centers, local businesses, retired executives, DDSD
resources, and have substantial knowledge of the Americans with Disabilities
Act (ADA); and
(v) complete
training on critical incident, abuse, neglect, and exploitation.
(b) Job coaches whether an agency
or individual provider, must:
(i) be at least
18 years of age;
(ii) have a high
school diploma or GED;
(iii) pass
criminal background check and abuse registry screen;
(iv) be qualified to perform the
service;
(v) have experience with
providing employment supports and training methods;
(vi) be knowledgeable about business and
employment resources;
(vii) have
the ability to successfully communicate with the employer and with the eligible
recipient and his or her coworkers to develop and encourage natural supports on
the job; and
(viii) complete
training on critical incident, abuse, neglect, and exploitation.
(2)
Qualifications of customized community group supports providers:
Agencies providing community group support services must hold a current
business license, and meet financial solvency, training, records management,
and quality assurance rules and requirements. Providers, whether an agency
staff or an individual provider must meet the following qualifications:
(a) must be at least 18 years of
age;
(b) pass criminal background
check and abuse registry screen;
(c) demonstrate capacity to perform required
tasks;
(d) complete training on
critical incident, abuse, neglect, and exploitation reporting; and
(e) have the ability to successfully
communicate with the eligible recipient.
G.
Service specific qualifications for
providers of health and wellness supports: In addition to the general
MAD qualifications, the following types of providers must meet additional
qualifications specific to the type of services provided.
(1)
Qualifications of extended state
plan skilled therapy providers for adults: Physical and occupational
therapists, speech/language pathologists, physical therapy assistants and
occupational therapy assistants must possess a therapy license in their
respective field from the New Mexico regulation and licensing department (RLD).
Speech clinical fellows must possess a clinical fellow license from the New
Mexico RLD.
(2)
Qualifications of behavior support consultation providers:
Behavior support consultation provider agencies shall have a current business
license issued by the state, county or city government, if required. Behavior
support consultation provider agencies shall comply with all applicable
federal, state, and rules and procedures regarding behavior consultation.
Providers of behavior support consultation services must possess qualifications
in at least one of the following areas:
(a) a
licensed psychiatrist by his or her New Mexico practice board;
(b) a regulation and licensing department
(RLD) licensed clinical psychologist;
(c) a RLD licensed psychologist associate,
(masters or Ph.D. level);
(d) a RLD
licensed independent social worker (LISW);
(e) a RLD licensed master social worker
(LMSW);
(f) a RLD licensed
professional clinical counselor (LPCC);
(g) a licensed clinical nurse specialist
(CNS) or a certified nurse practitioner (CNP) who is certified in psychiatric
nursing by a national nursing organization who can furnish services to adults
or children as his or her certification permits;
(h) a RLD licensed marriage and family
therapist (LMFT); or
(i) a RLD
licensed practicing art therapist (LPAT) by RLD.
(3)
Qualifications of nutritional
counseling providers: Nutritional counseling providers must maintain a
current registration as dietitians by the commission on dietetic registration
of the American dietetic association and licensed by the RLD, (Nutrition and
Dietetics Practice Act Section
61-7A-7
et seq., NMSA 1978).
(4)
Qualifications of private duty
nursing providers for adults: Direct nursing services are provided by
individuals who are currently licensed as registered or practical nurses by the
New Mexico state board of nursing, (Sections
61-3-14
and
61-3-18
NMSA 1978).
(5)
Qualifications of specialized therapy providers: For each type of
specialized therapy providers, the provider must hold the appropriate New
Mexico licensure or certification for the services he or she renders to an
eligible recipient:
(a) a RLD license in
acupuncture and oriental medicine;
(b) a license or certification with the
appropriate specialized training and clinical experience and supervision whose
scope of practice includes biofeedback;
(c) a RLD license in chiropractic
medicine;
(d) a license or
certification for which he or she has appropriate specialized training and
clinical experience and whose scope of practice includes cognitive
rehabilitation therapy;
(e) a RLD
license in a physical therapy, or occupational therapy, or speech therapy and
whose scope of practice includes hippotherapy with the appropriate specialized
training and experience;
(f) a RLD
license in massage therapy;
(g) a
RLD license in naprapathic medicine;
(h) a master's or a higher level behavioral
health degree with specialized play therapy training, clinical experience and
supervision and whose RLD license's scope of practice includes play therapy;
and
(i) a native American healer
who is recognized as a traditional healer within his or her
community.
H.
Service specific qualifications for other supports providers: In
addition to the general MAD qualifications, the following types of providers
must meet additional qualifications specific to the type of services provided.
(1)
Qualifications of transportation
providers:(a) Individual
transportation providers must:
(i) possess a
valid New Mexico driver's license with the appropriate
classification;
(ii) complete
training on critical incident, abuse, neglect and exploitation reporting
procedures; and
(iii) have a
current insurance policy and vehicle registration.
(b) Transportation vendors must hold a
current business license and tax identification number. Each agency will ensure
any vehicle used to transport an eligible recipient is equipped with an
up-to-date first aid kit. Each agency will ensure transportation drivers meet
the following qualifications:
(i) holds a
valid New Mexico driver's license of the appropriate classification to
transport an eligible recipient;
(ii) holds a current vehicle insurance policy
meeting New Mexico's insurance mandates in place for the vehicle used to
transport an eligible recipient; and
(iii) holds a New Mexico vehicle registration
for the vehicle used to transport an eligible recipient.
(2) Qualifications of
emergency response providers: Emergency response providers must comply
with all laws, rules and regulations of the state of New Mexico.
(3)
Qualifications of respite
providers: Respite services may be provided by eligible individual
respite providers; RN or practical nurses (LPN); or respite provider agencies.
Individual RN or LPN providers must be licensed by the New Mexico board of
nursing as an RN or LPN. Respite provider agencies must hold a current business
license, and meet financial solvency, training, records management and quality
assurance rules and requirements.
(4)
Qualifications of individual
directed goods and services vendors: Individual directed goods and
services vendors must hold a current business license and tax identification
for New Mexico and the federal government. Vendors for individual directed
goods and services are retail stores, community health centers, or medical
supply stores.
(5)
Qualifications of environmental modifications providers:
Environmental modification providers must possess an appropriate plumbing,
electrician, contractor or other appropriate New Mexico licensure.