New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 326 - CASE MANAGEMENT SERVICES
Part 10 - BRAIN INJURY SERVICES FUND PROGRAM
Section 8.326.10.7 - DEFINITIONS

A. "Acquired brain injury" (ABI) means a brain injury that is the result of trauma arising from an insult to the brain from an outside physical force via open or closed head injury; shaken baby syndrome; anoxia; near-drowning; electrical shock; brain infection; brain tumors; cerebrovascular lesions or insults, including stroke and aneurysm; or unintended toxic or chemical exposure. The definition excludes conditions that are congenital, degenerative, induced by birth trauma, or resulting from abuse of alcohol or other substances. The injury may be focal or diffuse, causing temporary or permanent impairments in cognitive, psychosocial or physical functioning affecting one or more areas of the brain and result in partial or total functional disability. Brain injury related impairments may affect one or more areas of functioning such as: cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; information processing; sensory, perceptual, and motor abilities; physical functioning; sleep; psychosocial and behavioral functioning; and, or speech.

B. "Activities of daily living" (ADL) means the basic tasks that are necessary for independent functioning to care for one's personal needs and may include bathing and showering, personal hygiene and grooming, dressing, toileting, transferring or moving the physical body in space while performing activities, and self-feeding. Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning but do allow an individual to live independently in their home or community; these include cleaning and maintaining the home, doing laundry, managing personal finances, preparing meals, shopping for groceries, taking prescribed medications, and using the telephone or other communication devices.

C. "Brain injury". See definition for acquired brain injury and traumatic brain injury.

D. "Brain injury services fund (BISF) program" means a non-medicaid program administered by HSD through programmatic oversight and contractual management of agencies, providing short-term crisis interim home and community-based services for eligible individuals living with brain injury, who have a defined crisis related to living with brain injury and no responsible funding source to pay for needed services or goods. Direct participant care services are provided through service coordination or BISF home and community-based services.

E. "Crisis" means an emergency or unstable situation that has reached a critical phase with a distinct possibility of adverse outcome and poses a serious potential danger. As related to a brain injury, a crisis may include homeless status, unemployment, substantial loss of income, lack of health insurance or means to pay for brain-injury related healthcare, separation from support systems, abandonment or other endangering circumstances. For the purposes of the BISF, the absence of service coordination, long-term care, long-term case management or need for long-term case management does not constitute a crisis.

F. "Crisis interim period" means a short-term period of six months upon which an enrolled participant can be reassessed to extend approved services for another six month period depending upon available funding and limited to no more than one consecutive year, if the crisis has not resolved and goals for independent living have not reached completion, or until another funding source has been obtained. Time limitations on services apply to both service coordination and to BISF HCBS.

G. "Education" means providing individuals living with brain injury training and understanding of brain injury, acquiring life skills or fulfilling activities of daily living, which can be applied day to day, to assist in the attainment of an independent lifestyle.

H. "Fiscal intermediary agency" means an agency that arranges for BISF home and community-based services and goods and processes payment or reimbursement for services and goods for eligible participants of the New Mexico human services department brain injury services fund program.

I. "Formulary" or "BISF formulary" means the list of medications approved by the BISF program for treatment of specific categories of brain injury symptoms and related conditions. Coverage is in the form of copayments for participants who have no other responsible payer sources. Approved generic and brand name medications are categorized by class or function. BISF service coordinators are authorized to review prescribed participant medications against the formulary in the event that other responsible payer sources to cover the medication do not exist prior to referral for BISF HCBS.

J. "Grievance" means a complaint or disagreement with regard to how or whether a service provided through the program is or can be provided.

K. "Home and community-based services" (HCBS) are defined as services to promote independent living that are provided in a person's home or community, i.e., those not provided under institutional care. BISF HCBS are those that may be required when there is an imminent risk to a participant's health and safety; there has been a sudden change in the medical, psychological or physical condition of a participant; when there is acceleration in the amount of services needed; when needs have suddenly changed; or when another payer source will not pay for the unique brain injury services assessed as a need.

L. "Human services department (HSD)" is the New Mexico state government agency that administers services to New Mexico's more vulnerable populations to improve health outcomes through state and federal funding. The brain injury services fund is administered through the medical assistance division and receives only state funding.

M. "ICD code" means an international classification of diseases diagnosis, which includes codes for traumatic and other acquired brain injuries and has been documented in writing by a duly licensed medical professional or psychologist for the purpose of assisting an individual with brain injury to qualify for the BISF program. Current ICD codes may be accepted from medical doctors (MDs), osteopathic doctors (DOs), certified nurse practitioners (CNPs), physician assistants (PAs), and Ph.D. psychologists.

N. "Imminent" means impending and threatening, referring to a crisis that is bound to happen with a clear and present danger to the health and safety of a person who has sustained a brain injury and who has exhausted all available resources.

O. "Independence" means the ability to live in a home and community setting and perform activities of daily living with little or no assistance from others while having access to available community resources.

P. "Individual" means a person living with brain injury and may be an applicant or a program participant.

Q. "Independent living plan" (ILP) means a written person-centered plan that outlines definite goals for resolving a participant's identified crisis which is designed to assist the participant toward greater independence; lists measurable objectives in the form of action steps and strategies that are targeted to comprehensively address and resolve each identified crisis; and specifies a plan for discharge. The ILP identifies all services and supports as well as payer sources that are assisting the participant toward greater independence, specifying those that pertain directly to service coordination and BISF HCBS. It must also list ancillary services and supports, not paid for by the BISF program, noting related payer sources, as well as services refused but needed to resolve or address identified crises.

R. "Interim" means a time period defined by the BISF program in which temporary services are provided. The interim period for the BISF program is six months.

S. "Legal resident of New Mexico" means a person residing in New Mexico at the time of application.

T. "Life skills coach" means a person, who may be defined as a "life coach", is certified through an accredited organization, and provides targeted customized training to an individual with brain injury to assist in relearning and completing activities of daily living while addressing related cognitive, behavioral or social impairments that are preventing the return to independent functioning.

U. "Participant" means a person living with brain injury, who has qualified for, been approved for, and is actively receiving BISF program services, while working toward greater independence and resolution of crisis needs.

V. "Payer of last resort" refers to the BISF Program as a source of funding available to pay for BISF HCBS only after all payer sources with responsibility to pay have been denied or exhausted including private insurance, medicaid, medicare, Indian health services, veterans administration, adult protective services and other state or federal programs, or community programs in which the participant participates voluntarily.

W. "Residency" means the status of a person who is a legal resident of New Mexico and is able to produce documentation of a physical address within New Mexico at which the person resides within a home and community setting. It does not include residence in an institution wherein the individual is unable to function independently.

X. "Risk" means a possible loss or injury, a hazard increasing the probability or chance that loss or injury will occur.

Y. "Self-determination" means the right of individuals to make decisions that direct the path their life follows with regard to medical, financial and all other matters, including the right to refuse measures needed to improve their outcome.

Z. "Service coordination" means the goal-oriented initiation, organization and management of a BISF participant's services, including determination of eligibility, initial and interim assessments, development and monitoring of the participant's independent living plan (ILP), referrals for BISF program and community resources, assistance with benefits applications for other payer sources, and problem-solving to assist in the resolution of the crisis that motivated entry to the BISF program, while moving the participant toward greater independence in daily living. Service coordination may continue during resolution of an identified crisis need. Service coordination is not defined as case management, and the need for long-term case management does not constitute a qualifying crisis for remaining on the BISF.

AA. "Short-term" means an intervention period with beginning and end points within which BISF funding for service coordination or BISF HCBS may be used to prevent or alleviate a crisis situation until circumstances stabilize or other funding is obtained.

BB. "Traumatic brain injury (TBI)" means an insult to the brain from an outside physical force that may or may not have produced a diminished or altered state of consciousness causing temporary or permanent impairments in one or more areas of the brain and resulting in partial or total functional disability and or psychosocial disorientation. The term applies to open or closed head injuries resulting in an impairment of cognitive, psychosocial or physical functions. Brain injury related impairments may occur in one or more areas such as: cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; information processing, sensory, perceptual, and motor abilities; physical functioning; sleep; psychosocial and behavioral functioning; and speech.