N.M. Admin. Code § 8.314.5.10 - ELIGIBLE PROVIDERS
A. Health care
to eligible recipients is furnished by a variety of providers and provider
groups. The reimbursement and billing for these services is administered by
MAD. Upon approval of a New Mexico MAD provider participation agreement (PPA)
by MAD or its designee, licensed practitioners, facilities, and other providers
of services that meet applicable requirements are eligible to be reimbursed for
furnishing covered services to eligible recipients. A provider must be enrolled
before submitting a claim for payment to the MAD claims processing contractors.
MAD makes available on the HSD/MAD website, on other program-specific websites,
or in hard copy format, information necessary to participate in health care
programs administered by HSD or its authorized agents, including New Mexico
administrative code (NMAC) rules, billing instructions, utilization review
instructions, EVV requirements and instructions, service definitions and
service standards and other pertinent materials. When enrolled, a provider
receives instruction on how to access these documents. It is the provider's
responsibility to access these instructions, to understand the information
provided and to comply with the requirements. The provider must contact HSD or
its authorized agents to obtain answers to questions related to the material or
not covered by the material. To be eligible for reimbursement, a provider must
adhere to the provisions of the MAD PPA and all applicable statutes,
regulations, and executive orders. MAD or its selected claims processing
contractor issues payments to a provider using electronic funds transfer (EFT)
only.
B. All DDW eligible providers
must be approved by DOH or its designee and have an approved MAD PPA and a DOH
provider agreement.
C. MAD through
its designee, DOH/DDSD, follows a subcontractor model for certain DDW services.
The agency, following the DOH/DDSD model, must ensure that its subcontractors
or employees meet all required qualifications. The agency must provide
oversight of subcontractors and supervision of employees to ensure that all
required MAD and DOH/DDSD qualifications and service standards are met. In
addition, the agency must provide oversight and supervision of subcontractors
and employees to ensure that services are delivered in accordance with all
requirements set forth by the DOH/DDSD DDW service definition, all requirements
outlined in the DDW services standards, applicable NMAC rules, MAD supplements,
and as applicable, their New Mexico licensing board's scope of practice and
licensure. Pursuant to federal regulations, an agency may not employ or
subcontract with the spouse of an eligible recipient or the parent of an
eligible recipient under 18 years of age to provide direct care services to the
eligible recipient.
D.
Qualifications of case management provider agency: A case
management provider agency, its case managers, whether subcontractors or
employees must comply with
8.314.5.10 NMAC. In addition, case
management provider agency must ensure that a case manager meets the following
qualifications:
(1) one year of clinical
experience, related to the target population; and
(2) one or more of the following:
(a) hold a current social worker license as
defined by the New Mexico regulation and licensing department (RLD);
or
(b) hold a current registered
nurse (RN) license as defined by the New Mexico board of nursing; or
(c) hold a bachelor's or master's degree in
social work, psychology, sociology, counseling, nursing, special education, or
a closely related field or have a minimum of six years of direct experience
related to the delivery of social services to people with disabilities;
or
(d) have a high school diploma
or GED and a minimum of six years of direct experience related to the delivery
of social services to people with disabilities.
(3) comply with all training requirements as
specified by DOH/DDSD; and
(4) have
received written notification from DOH that they do not have a disqualifying
conviction after submitting to the caregiver criminal history screening
(CCHS);
(5) does not provide any
direct waiver services through the same 1915 (c) HCBS waiver program;
and
(6) any exception to the above
must be approved by DOH/DDSD.
E.
Qualifications of respite provider
agency: A respite provider agency must comply and ensure that all direct
support personnel, whether subcontractors or employees, comply with
8.314.5.10 NMAC. In addition,
respite provider agencies and direct support personnel must:
(1) comply with all training requirements as
specified by DOH;
(2) have and
maintain documentation of current cardiopulmonary resuscitation (CPR) and first
aid certification;
(3) have written
notification from DOH that they do not have a disqualifying conviction after
submitting to the CCHS; and
(4)
comply with all EVV requirements as defined by the
21st Century CURES Act and implemented by MAD
including but not limited to documenting service provision using the approved
EVV system.
F.
Qualifications of adult nursing provider agencies: Adult nursing
provider agencies must ensure all subcontractors or employees, including
nurses, comply with DOH DDW service definitions, DDW service standards,
applicable NMAC rules, MAD billing instructions, utilization review
instructions, and supplements, and applicable federal and state laws, rules and
statutes. Direct nursing services shall be provided by a New Mexico licensed RN
or licensed practical nurse (LPN), have a minimum of one year experience as a
licensed nurse, and must comply with all aspects of the New Mexico Nursing
Practice Act, including supervision and delegation requirements of specific
nursing function and
8.314.5.10 NMAC.
G.
Qualifications of therapy provider
agency: A therapy provider agency must comply and ensure that each of
its therapists including physical therapists (PT), occupational therapists
(OT), and speech therapists (SLP), physical therapy assistants (PTA), and
certified occupational therapy assistants (COTA), whether a subcontractor or
employee complies with
8.314.5.10 NMAC.
H.
Qualifications for living supports
provider agency: Living supports consist of family living, supported
living, and intensive medical living supports. A living supports provider
agency must comply with the accreditation policy and all requirements set forth
by the DOH, DDW service definitions, all requirements outlined in the DDW
service standards and the applicable NMAC rules. A living supports provider
agency must ensure that all direct support personnel, whether subcontractor or
employees, meet all qualifications set forth by DOH, DDW service standards, and
applicable NMAC rules.
(1) A living supports
provider agency and direct support personnel must:
(a) comply with all training requirements as
specified by DOH;
(b) have and
maintain documentation of current CPR and first aid certification;
and
(c) have written notification
from DOH that they do not have a disqualifying conviction after submitting to
the CCHS.
(2) A family
living provider agency must ensure that all direct support personnel, whether a
subcontractor or employee, meet all qualifications set forth by DOH and the DDW
service standards and the applicable NMAC rules. Legal guardians who are also
natural or adoptive family members who meet the DOH/DDSD requirements and are
approved to provide family living services may be paid for providing services.
A family living provider agency must employ or subcontract with at least one registered or licensed dietician or licensed nutritionist. A family living provider agency must also be an adult nursing services provider and must employ or subcontract with at least one licensed RN; employ or subcontract with at least one additional nurse for on call services and comply with the New Mexico Nurse Practice Act, including supervision and delegation requirements of specific nursing functions. The number of nurses (RNs and LPNs) must be sufficient to meet the routine and on call health care needs of the individuals. Both the direct support personnel employed by or subcontracting with the provider agency and the physical home setting must be approved through a home study completed prior to the initiation of services, revised with any change in family composition, move to a new home, or other significant event and periodically thereafter as required of the provider agency.
(3) A supported living provider
agency must ensure that all direct support personnel meet all qualifications
set forth by DOH and the applicable NMAC rules and the DDW service standards. A
supported living provider agency must employ or subcontract with at least one
registered or licensed dietician or licensed nutritionist. The number of RD/LDs
employed or under contract must be sufficient to meet the routine nutritional
needs of the individuals. They must employ or subcontract with at least one
licensed RN, employ or subcontract with at least one additional nurse for on
call and services, and comply with the New Mexico Nurse Practice Act, including
supervision and delegation requirements of specific nursing functions. The
number of nurses (RNs and LPNs) must be sufficient to meet the routine and on
call health care needs of the individuals.
(4) An intensive medical living supports
provider agency must employ or subcontract with at least one registered or
licensed dietician or licensed nutritionist. The number of RD/LDs employed or
under contract must be sufficient to meet the routine nutritional needs of the
individuals. They must employ or subcontract with at least one New Mexico
licensed RN who must have a minimum of one year of nursing experience employ or
subcontract with at least one additional nurse for on call services and comply
with the New Mexico Nursing Practice Act including supervision and delegation
requirements of specific nursing functions. The number of nurses (RNs and LPNs)
must be sufficient to meet the routine and on call health care needs of the
individuals.
I.
Qualifications of a customized community supports provider agency:
A customized community supports provider agency must comply with and ensure
that all direct support personnel, whether subcontractor or employees, comply
with 8.314.5.10 NMAC. A customized
community supports provider agency and direct support personnel must:
(1) comply with all training requirements as
specified by DOH;
(2) have and
maintain documentation of current CPR and first aid certification;
and
(3) have written notification
from DOH that they do not have a disqualifying conviction after submitting to
the CCHS.
J.
Qualifications of a community integrated employment provider
agency: A community integrated employment provider agency must comply
with and ensure that all direct support personnel, whether subcontractor or
employees, comply with
8.314.5.10 NMAC. A community
integrated employment provider agency and direct support personnel must:
(1) comply with all training requirements as
specified by DOH;
(2) have and
maintain documentation of current CPR and first aid certification;
and
(3) have written notification
from DOH that they do not have a disqualifying conviction after submitting to
the CCHS.
K.
Qualifications of a behavioral support consultation provider
agency: A behavioral support consultation provider agency must comply
with and ensure that all behavioral support consultants, whether subcontractors
or employees, comply with
8.314.5.10 NMAC.
(1) A provider of behavioral support
consultation services must be currently licensed in one of the following
professions and maintain that licensure with the appropriate RLD board or
licensing authority:
(a) a licensed clinical
mental health counselor (LMHC), or
(b) a licensed psychologist; or
(c) a licensed psychologist associate,
(masters or Ph.D. level); or
(d) a
licensed independent social worker (LISW) or a licensed clinical social worker
(LCSW); or
(e) a licensed master
social worker (LMSW); or
(f) a
licensed professional clinical mental health counselor (LPCC); or
(g) a licensed marriage and family therapist
(LMFT); or
(h) a licensed
professional art therapist (LPAT); or
(i) Other related licenses and qualifications
may be considered with DOH's prior written approval.
(2) Providers of behavioral support
consultation services must have a minimum of one year of experience working
with individuals with intellectual or developmental disabilities.
(3) Behavioral support consultation providers
must participate in training in accordance with the DOH/DDSD training
policy.
L.
Qualifications of a nutritional counseling provider agency: A
nutritional counseling provider agency must comply with and ensure that all
nutritional counseling providers, whether subcontractors or employees comply
with 8.314.5.10 NMAC. In addition, a
nutritional counseling provider must be registered as a dietitian or a licensed
nutritionist by the commission on dietetic registration of the American
dietetic association and be licensed by RLD as a nutrition counselor.
M.
Qualifications of an environmental
modification provider agency: An environmental modification contractor
and their subcontractors and employees must be bonded, licensed by RLD, and
authorized by DOH to complete the specified project. An environmental
modification provider agency must comply with
8.314.5.10 NMAC. All services shall
be provided in accordance with applicable federal, state and local building
codes.
N.
Qualifications of a
crisis supports provider agency: A crisis supports provider agency must
comply with and must ensure that direct support personnel, whether
subcontractors or employees, comply with
8.314.5.10 NMAC. In addition, a
crisis supports provider agency and direct support personnel must:
(1) comply with all training requirements as
specified by DOH;
(2) have and
maintain documentation of current CPR and first aid certification;
and
(3) have written notification
from DOH that they do not have a disqualifying conviction after submitting to
the CCHS.
O.
Qualifications for a non-medical transportation provider agency: A
non-medical transportation provider agency must comply with
8.314.5.10 NMAC. In addition, a
non-medical transportation provider must have a business license and drivers
must have a valid driver's license and not have a disqualifying conviction
after submitting to the CCHS. Must have written notification from DOH that they
do not have a disqualifying conviction after submitting to the CCHS.
P.
Qualifications of an assistive
technology provider agency: An assistive technology purchasing agent
provider and agency must comply with
8.314.5.10 NMAC, demonstrate fiscal
solvency when functioning as a payee for this service. Assistive technology
providers may also be the direct vendors of approved technology.
Q.
Qualifications of an independent
living transition service provider agency: An independent living
transition service provider agency must comply with
8.314.5.10 NMAC, demonstrate fiscal
solvency and function as a payee for this service.
R.
Qualifications of a remote personal
support technology provider agency: Remote personal support technology
provider agencies must comply with
8.314.5.10 NMAC. This includes
having a current business license and must demonstrate fiscal solvency and
function as a payee of services. In addition, remote personal support
technology provider agencies must comply with all laws, rules, and regulations
of the federal communications commission (FCC) for
telecommunications.
S.
Qualifications of a preliminary risk screening and consultation (PRSC)
related to inappropriate sexual behavior provider agency: A PRSC
provider agency must comply with
8.314.5.10 NMAC and all training
requirements as specified by DOH. Additionally, the PRSC provider agency must
subcontract with or employ the evaluator, who at a minimum must be:
(1) an RLD independently licensed behavioral
health practitioner, such as an LPCC, LCSW, LMFT, LISW, or a psychologist;
or
(2) a practitioner who holds a
master's or doctoral degree in a behavior health related field from an
accredited college or university.
T.
Qualifications of a socialization
and sexuality education provider agency: A socialization and sexuality
education provider agency must comply with
8.314.5.10 NMAC. A provider agency
must be approved by the DOH, bureau of behavioral support (BBS) as a
socialization and sexuality education provider and must meet training
requirements as specified by DOH. In addition, a socialization and sexuality
education provider agency must employ or contract with a provider who has one
of the following qualifications for rendering the service:
(1) a master's degree or higher in
psychology;
(2) a master's degree
or higher in counseling;
(3) a
master's degree or higher in special education;
(4) a master's degree or higher in social
work;
(5) a master's degree or
higher in a related field;
(6) a RN
or LPN;
(7) a bachelor's degree in
special education or a related field such as psychology or social
work;
(8) a certification in
special education;
(9) a New Mexico
level three recreational therapy instructional support provider license;
or
(10) a certified therapeutic
recreation therapist (CTRS) obtained through the national council for
therapeutic recreation.
U.
Qualifications of a customized
in-home supports provider agency: A customized in-home supports provider
agency must comply with and ensure that direct support personnel, whether
subcontractors or employees, comply with
8.314.5.10 NMAC. Legal guardians
who are also natural or adoptive family members, relatives, or natural family
members that meet the DOH/DDSD requirements and are approved to provide
customized in-home supports may be paid for providing services. A customized
in-home supports provider agency and direct support personnel must:
(1) comply with all training requirements as
specified by DOH;
(2) have and
maintain documentation of current CPR and first aid certification;
and
(3) have written notification
from DOH that they do not have a disqualifying conviction after submitting to
the CCHS.
(4) comply with all EVV
requirements as defined by the 21st Century CURES
Act and implemented by MAD including but not limited to documenting service
provision using the approved EVV system.
V.
Qualifications of a supplemental
dental care provider agency: A supplemental dental care provider agency
must comply with
8.314.5.10 NMAC. A supplemental
dental care provider must contract with a New Mexico licensed dentist and
dental hygienist who are licensed by RLD. The supplemental dental care provider
will ensure that a RLD licensed dentist provides the oral examination; ensure
that a RLD licensed dental hygienist provides all routine dental cleaning
services; demonstrate fiscal solvency; and function as a payee for the
service.
Notes
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