Current through Register Vol. 35, No. 18, September 24, 2024
Supports waiver eligible recipients have responsibilities to
participate in the program. Failure to comply with these responsibilities or
other program rules and service standards can result in termination from the
program. The eligible recipient has the following responsibilities:
A. To maintain eligibility the recipient must
complete required documentation demonstrating medical and financial eligibility
both upon application and annually at recertification, and seek assistance with
the application and the recertification process as needed from a community
supports coordinator (CSC).
B. To
participate in the supports waiver program, the eligible recipient must:
(1) comply with applicable NMAC rules to
include this rule and supports waiver service standards and requirements that
govern the program;
(2) collaborate
with the CSC to choose between the agency-based or participant directed service
delivery models, and determine support needs related to planning and self
direction as applicable;
(3)
collaborate with the CSC to develop an ISP and budget using the IBA in
accordance with applicable NMAC rules to include this rule and supports waiver
service standards;
(4) use supports
waiver program funds appropriately by only requesting and purchasing goods and
services covered by the supports waiver program in accordance with program
rules which are identified in the eligible recipient's approved ISP and
budget;
(5) comply with the
approved ISP and not exceed the AAB;
(a) if
the eligible recipient, due to mismanangement or failure to properly track
expenditures, prematurely depletes the AAB amount during an ISP year, the
failure to properly manage the AAB does not substantiate a claim for a budget
increase (e.g. if all of the AAB is expended within the first three months of
the ISP year, it is not justification for an increase in the budget for the ISP
year);
(b) revisions to the AAB may
occur within the ISP year, and the eligible recipient is responsible for
ensuring that all expenditures are in compliance with the most current AAB in
effect;
(i) the ISP must be amended to reflect
a change in the eligible recipient's needs or circumstances before any
revisions to the AAB can be requested;
(ii) other than for critical health and
safety reasons, budget revisions may not be submitted to the TPA for review
within the last 60 calendar days of the budget year;
(c) no supports waiver program funds can be
used to purchase goods or services prior to TPA approval of the ISP and annual
budget request;
(d) any funds not
utilized within the ISP and AAB year cannot be carried over into the following
year;
(6) access CSC
services based upon identified need(s) in order to carry out the approved
ISP;
(7) collaborate with the CSC
to appropriately document service delivery and maintain documents for evidence
of services received;
(8) report
concerns or problems with any part of the supports waiver program to the
community supports coordinator or if the concern or problem is with the CSC, to
DOH;
(9) work with the TPA by
providing documentation and information as requested;
(10) respond to requests for additional
documentation and information from the CSC provider, FMA, and the TPA within
the required deadlines;
(11) report
to the local HSD income support division (ISD) office within 10 calendar days
any change in circumstances, including a change in address, which might affect
eligibility for the program; changes in address or other contact information
must also be reported to the CSC provider and the financial management agency
(FMA) within 10 calendar days;
(12)
report to the TPA and CSC provider if hospitalized for more than three
consecutive nights so that an appropriate LOC can be obtained;
(13) have monthly contact and meet
face-to-face quarterly with the CSC, as required by the DOH; and
(14) comply with all electronic visit
verification (EVV) requirements.
C.
Specific responsbilities for
eligible recipient in participant directed service delivery model: In
addition to the requirements in Subsection A and B of 8.314.7.11 NMAC, the
eligible recipient must have an employer of record (EOR) to participate in the
participant directed service delivery model. The EOR may be the eligible
recipient unless the eligible recipient is a minor or has a plenary or limited
guardianship or conservatorship over financial matters in place. An EOR must be
the waiver participant or an EOR must be a legal representative of the
recipient. The eligible recipient as their own EOR or the designated EOR must:
(1) direct the work of supports waiver
employees, including recruiting, hiring, managing and terminating all
employees;
(2) direct the work of
any vendors contracted to perform services;
(3) track expenditures for employee payroll,
goods, and services;
(4) authorize
the payment of timesheets and vendor payment requests by the FMA;
(5) keep track of all budget expenditures and
ensure that all expenditures are within the AAB;
(6) submit all required documents to the FMA
to meet employer-related responsibilities. This includes, but is not limited
to, documents for payment to employees and vendors and payment of taxes and
other financial obligations within required timelines;
(7) complete all trainings within the
required timeframes by the DOH or medical assistance division (MAD);
(8) ensure that all employees have registered
and completed required trainings within the timeframes required by the DOH or
MAD, identified in the ISP or identified by the EOR;
(9) report any incidents of abuse, neglect or
exploitation to the appropriate state agency;
(10) arrange for the delivery of services,
supports and goods;
(11) maintain
records and documentation for at least six years from first date of service and
ongoing; and
(12) comply with all
electronic visit verification (EVV) requirements.
D.
Voluntary termination: The
supports waiver eligibile recipient may voluntarily terminate services through
the supports waiver and will not lose their place on DD waiver wait
list.
E.
Involuntary
termination: A supports waiver eligible recipient may be terminated
involuntarily by MAD and DOH for the following:
(1) the eligible recipient refuses to comply
with 8.314.7 NMAC and the supports waiver service standards, after receiving
focused technical assistance from DOH and MAD program staff, CSC, or FMA, which
is supported by documentation of the efforts to assist the eligible
recipient;
(2) the eligible
recipient is an immediate risk to their health or safety, imminent risk of
death or serious bodily injury, by continued participant direction of services.
Examples include but are not limited to the following:
(a) the eligible recipient refuses to include
and maintain services in their ISP and AAB that would address health and safety
issues identified in their ISP or challenges the ISP after repeated and focused
technical assistance and support from program staff, CSC, or FMA;
(b) the eligible recipient is experiencing
significant health or safety needs, and either refuses to incorporate a plan to
address health and safety needs or document applicable choices in
ISP;
(c) the eligible recipient
exhibits behaviors which endanger themselves or others after repeated and
focused technical assistance and support from program staff, CSC, or
FMA.
(3) the eligible
recipient misuses suppports waiver funds following repeated and focused
technical assistance and support from the CSC or FMA, which is supported by
documentation;
(4) the eligible
recipient commits medicaid fraud;
(5) when the DOH is notified that the
eligible recipient continues to utilize either an employee or a vendor, or
both, who have consistently been substantiated against for abuse, neglect or
exploitation while providing supports waiver services after notification of
this by DOH;
(6) the eligible
recipient who is involuntarily terminated from the supports waiver will remain
on the DD waiver wait list, and will continue to have access to other medicaid
benefits based on eligibility.
