9 SELF-DIRECTED COMMUNITY BENEFIT (SDCB) Revision dates

9 SELF-DIRECTED COMMUNITY BENEFIT (SDCB)

Revision dates: August 15, 2014; February 23, 2015; March 1, 2016, March 1, 2017

Effective date: January 1, 2014

PURPOSE

The Self- Directed Community Benefit (SDCB) is intended to provide a community-based alternative to

institutional care that facilitates greater member choice, direction and control over covered services and

supports.

SDCB provides self-directed Home and Community-Based Services (HCBS) to eligible members who

are living with conditions associated with aging, disabilities, certain traumatic or acquired brain injuries

(BI), acquired immunodeficiency syndrome (AIDS).

Home and Community-Based Services shall meet the following standards:

A. are integrated and support full access of individuals receiving Medicaid HCBS to the greater

community, including opportunities to seek employment, and work in competitive integrated

settings, engage in community life, control personal resources, and receive services in the

community, to the same degree of access as individuals not receiving Medicaid HCBS;

B. are selected by the individual from among setting options including non-disability specific

settings. The setting options are identified and documented in the person-centered service plan and

are based on the individual’s needs and preferences;

C. ensure an individual’s rights of privacy, dignity and respect, and freedom from coercion and

restraint;

D. optimize, but do not regiment, individual initiative, autonomy, and independence in making life

choices, including but not limited to, daily activities, physical environment, and with whom to

interact; and

E. facilitate individual choice regarding services and supports, and who provides them.

GUIDING PRINCIPLES

All members:

Have value and potential;

Will be viewed in terms of their abilities;

Have the right to participate and be fully included in their communities; and

Have the right to live, work, learn, and receive services and supports to meet their individual needs, in the

most integrated settings possible within their community.

PHILOSOPHY OF SELF-DIRECTION

Self-direction is a tool that leads to self-determination, through which members can have greater control

over their lives and have more freedom to lead a meaningful life in the community. Within the context of

SDCB, self-direction means members choose which covered services they need, as identified in the most

recent Comprehensive Needs Assessment (CNA). SDCB members also decide when, where and how

those SDCB covered services will be provided and who they want to provide them. SDCB members

decide who they want to assist them with planning and managing their SDCB covered services within a

managed care environment. Self-Direction means that SDCB members have more choice, control,

flexibility, freedom and responsibility in directing their community benefits.

DEFINITIONS AND ACRONYMS

1. Authorized Agent (AA): The member may choose to appoint an authorized agent designated to

have access to medical and financial information for the purpose of offering support and assisting

the member in understanding community benefit services. The member may designate a person to

act as an authorized agent by signing a release of information form indicating the member’s

consent to the release of confidential information. The authorized agent will not have the

authority to direct SDCB. Directing services remains the sole responsibility of the member or

his/her legal representative.

The member’s authorized agent does not require a legal relationship with the member. While the

member’s authorized agent can be a service provider for the member, the authorized agent cannot

serve as the member’s care coordinator/support broker. If the authorized agent is an employee,

he/she cannot sign his/her own timesheet.

2. Authorized Representative (AR): Authorized representative is an individual designated to

represent and act on the member’s behalf. The member or authorized representative must provide

formal documentation authorizing the named individual or individuals to access the identified case

information for a specified purpose and time frame. An authorized representative may be an

attorney representing a person or household, a person acting under the authority of a valid power

of attorney, a guardian, or any other individual or individuals designated in writing by the eligible

recipient or member.

3. Centers for Medicare and Medicaid Services (CMS): federal agency within the United States

Department of Health and Human Services that works in partnership with the states to administer

Medicaid. CMS must approve all Medicaid programs.

4. Employer of Record (EOR): Individual responsible for directing the work of SDCB employees

by recruiting, hiring, training, supervising and terminating employees, and ensuring payment to

employees and vendors.

5. Financial Management Agency (FMA): Contracted with each Centennial Care MCO and helps

the SDCB member implement the approved SDCB Care Plan by receiving and processing payment

requests for the SDCB member’s employees and vendors, tracking the SDCB expenditures and

credentialing the SDCB employees and vendors.

6. FOCoSonline: The web-based system used by the SDCB FMA for receiving and processing

SDCB payment requests. The FOCoSonline system is also used by SDCB members, care

coordinators, and support brokers to develop and submit SDCB care plan/budget requests for

MCO/UR review, and to monitor utilization and spending throughout the SDCB care plan year.

7. Human Services Department (HSD): Designated by the Center for Medicare and Medicaid

Services (CMS) as the Medicaid administering agency in New Mexico. HSD is also responsible

for operating the SDCB Home and Community Based Services for populations that meet the

Nursing Facility Level of Care (Disabled & Elderly, Brain Injury, and AIDS).

8. Legally Responsible Individual (LRI): A person who has a duty under State law to care for

another person. This category typically includes: the parent (biological or adoptive) of a minor

child; the guardian of a minor child who must provide care to the child; or the spouse of a SDCB

member. Payment may not be made to a legally responsible individual for the provision of

personal care or similar services that the legally responsible individual would ordinarily perform

or be responsible to perform on behalf of a SDCB member. Exceptions to this prohibition may be

made under extraordinary circumstances specified by the State, utilizing documentation specified

by the State and only after approval by the appropriate MCO.

9. Managed Care Organization/Utilization Review (MCO/UR): Provides services related to

medical eligibility determination and re-determination, and NFLOC for SDCB members. The

MCO also performs utilization management duties – review and approval or denial of each

individual services or related goods requested in the SDCB care plan/budget.

10. Quality Assurance and Quality Improvement (QA/QI): Processes utilized by state and federal

governments, programs and providers whereby appropriate oversight and monitoring of

community benefits of assurances and other measures provide information about the health and

welfare of members and the delivery of appropriate services. This information is then collected,

analyzed and used to improve services and outcomes and to meet requirements by state and

federal agencies. Quality plans, systems and processes are designed and implemented to maintain

continuous quality improvement.

11. Reconsideration: SDCB members who disagree with an adverse decision made by the MCO/UR

may submit a written request through a care coordinator/support broker to the MCO/UR for a

reconsideration of the adverse decision. These requests must include new, additional information

that is different from, or expands on, the information submitted with the initial request.

12. Self-Directed Community Benefit (SDCB): Is a component of the State’s 1115 (c) Medicaid

Managed Care waiver which allows eligible members the option to access SDCB Medicaid funds,

using the essential elements of person-centered planning, individualized budgeting, member

protections, and quality assurance and quality improvement. SDCB members have choices

(among the state-determined SDCB services and related goods) in identifying, accessing and

managing the services and related goods needed to meet their personal goals.

13. SDCB Budget: The maximum budget allotment available to an eligible SDCB member,

determined by his/her established nursing facility level-of-care (NF-LOC), comprehensive needs

assessment (CNA), and the amount and type of services the member was receiving in the ABCB.

Based on this maximum amount, the eligible SDCB member will develop a SDCB care plan to

meet his/her assessed functional, medical and habilitative needs to enable that member to remain

in the community.

14. SDCB Care Plan: A plan that includes approved SDCB services of the SDCB member’s choice;

the projected cost, frequency and duration of services and related goods; the type of provider who

will furnish each service or related good; other services and related goods to be used by the

member. Each SDCB care plan shall include a back-up plan which lists who the member will

contact if regularly scheduled employees or service providers are unable to report to work. The

SDCB care plan is mandatory for all SDCB members and must be processed through the

FOCoSonline system.

15. SDCB Member: An individual who meets the medical and financial eligibility and is approved to

receive services through the SDCB after having receiving ABCB for a minimum of 120 calendar

days.

16. Support Broker (SB): An individual who provides support to SDCB members and assists the

member (or the member’s family or representative, as appropriate) in arranging for, directing and

managing SDCB services and supports as well as developing, implementing and monitoring the

SDCB care plan and budget. Individual support brokers work for MCO-approved support broker

agencies or may be directly employed by a MCO.

SDCB MEMBER RIGHTS

A SDCB member has the right to:

1. Decide where and with whom to live;

2. Choose his/her own work or productive activity;

3. Choose how to establish community and personal relationships;

4. Make decisions regarding his/her own support, based upon informed choice;

5. Be respected and supported during the decision-making process and in the decisions made;

6. Recruit, hire, train, schedule, supervise and terminate SDCB service providers, as necessary;

7. Receive training, resources and information related to SDCB in a format that meets the American

with Disabilities Act (ADA) requirements;

8. Have the right to appeal denial decisions through the MCO appeals and state fair hearing

processes;

9. Transfer to programs that are not self-directed; and

10. Receive culturally competent services.

SDCB MEMBER RESPONSIBILITIES

SDCB members have certain responsibilities in order to participate in the program. Failure to comply

with these responsibilities or other program rules and policies can result in an involuntary termination

from the SDCB.

The most basic responsibility of each SDCB member is to maintain his/her financial and medical

eligibility to remain in the SDCB. This includes completing the required documentation to determine

initial and annual financial eligibility and participating in the initial and annual comprehensive needs

assessment (CNA) conducted by the Managed Care Organization (MCO). The care coordinator and

support broker may assist with the application and recertification process as needed.

1. Ongoing SDCB Member Responsibilities:

A. Comply with the rules and policies that govern the SDCB;

B. Maintain an open and collaborative relationship with the care coordinator and support

broker, and work together to determine support needs related to the activities of self-

direction, develop an appropriate SDCB care plan/budget request, receive necessary

assistance with carrying out the approved SDCB care plan/budget, and with documenting

service delivery;

C. Communicate with the support broker at least once a month, either in person or by phone,

and meet with the support broker in-person at least once every three (3) months. Report

concerns or problems with any part of SDCB to the support broker or care coordinator;

D. Use SDCB funds appropriately by only requesting services and related goods covered by

the SDCB and only purchasing services and related goods after they have been approved

by the MCO/UR;

E. Comply with the approved SDCB care plan and not spend more than the authorized

budget;

F. Work with the care coordinator by attending scheduled meetings and assessments, in the

member’s home as required, and providing documentation as requested;

G. Respond to requests for additional documentation and information from the care

coordinator, support broker, Fiscal Management Agency (FMA), and the MCO/UR within

the required deadlines;

H. Report to the local Income Support Division (ISD) office, within 10 business days, any

change in circumstances, including, but not limited to, a change in address or

hospitalization, which may affect eligibility for the program. Changes in address or other

contact information must also be reported to the care coordinator, support broker and the

FMA within 10 calendar days;

I. Report to the care coordinator and support broker if hospitalized for more than three (3)

consecutive nights so that a new appropriate LOC can be obtained; and

J. Communicate with SDCB service providers, State contractors and State personnel in a

respectful, non-abusive and non-threatening manner.

2. Member/Employer of Record (EOR) Responsibilities: Every SDCB member must have an

Employer of Record (EOR) who is responsible for directing the work of SDCB employees, and

ensuring accurate and timely employee and vendor payment requests are sent to the FMA for

processing. A member may be his/her own EOR unless the member is a minor, or has a plenary

or limited guardianship or conservatorship over financial matters in place. If a SDCB member’s

Power of Attorney includes the authority to make decisions regarding financial matters, the

POA must be the member’s EOR due to the financial responsibilities inherent in the SDCB

program. A designated EOR may not be an employee of the member. Members may also

designate an individual of their choice to serve as their EOR, subject to the EOR meeting the

qualifications specified in the SDCB rules and policies. The care coordinator conducts an EOR

Self-Assessment with the SDCB member to determine if the member will require assistance in

fulfilling the EOR responsibilities. If the EOR Self-Assessment demonstrates that the member is

not able to be his/her own EOR, and the member does not designate a qualified individual to serve

as the EOR, the member shall not be allowed to transfer to SDCB until the member designates a

suitable EOR.

An EOR is responsible for recruiting, hiring, training, supervising and terminating employees, as

necessary. The EOR will establish work schedules and tasks and provide relevant training. The

EOR will keep track of SDCB budget amounts spent on paying employees and for approved

services and related goods. EORs authorize the payment of timesheets and invoices by the

Financial Management Agency (FMA). An EOR cannot be paid for any services utilized by the

SDCB member for whom he or she is the EOR and the EOR cannot be paid for performing the

EOR functions.

The SDCB member/EOR responsibilities include:

A. Arranging for the delivery of SDCB services, supports and related goods as approved in

the SDCB care plan;

B. Verifying and attesting that employees meet the minimum qualifications for employment

as required by the SDCB;

C. Orienting, training, and directing SDCB employees in providing the services that are

described and authorized in the member’s SDCB care plan;

D. Establishing a mutually agreeable schedule for employees’ services in writing and

providing fair notice of changes in the employee’s work schedule in the event of

unforeseen circumstances or emergencies;

E. Submitting all necessary and required documents to the FMA. Documents must be

completed and provided to the FMA according to the timelines and rules established by the

State. Documents include, but are not limited to, vendor and employee agreements, vendor

information forms, criminal background check forms, time-sheets, payment request forms

(PRFs) and invoices, updated employee information, and other documentation needed by

the FMA to process timely and accurate payment to SDCB providers;

F. Agreeing that SDCB employees may not begin work until all materials necessary for a

criminal background check have been received by the FMA and the employee has

successfully passed the Consolidated Online Registry (COR) Background Check;

G. Agreeing to select or employ the employee on an interim (temporary) basis until a final

criminal background check (CBC) has been successfully completed, for those crimes

determined to be disqualifying convictions as stated in NMSA 1978, Section 29-17-3. The

EOR discusses this with the employee and reserves the right to dismiss the employee based

on the results of the CBC;

H. Providing fair notice of changes in the employee’s work schedule in the event of

unforeseen circumstances or emergencies;

I. Review and approve/deny completed employee timesheets in order to pay employees

according to the FMA predetermined payroll schedule. Net wages are gross earnings

calculated according to the employee’s pay rate, minus payroll deductions for the

employee’s share of applicable state, federal, and local payroll withholdings;

J. Reporting any incidents of abuse, neglect or exploitation by any employee or other service

provider to the support broker and/or care coordinator;

K. Maintaining SDCB employee and service records and documentation in accordance with

SDCB rules and policies, and federal and state employment rules;

L. Fully cooperating with the NM Department of Workforce Solutions (DWS) in any

investigations or other matters related to his/her SDCB employees;

M. Fully cooperating with the State’s worker’s compensation carrier, currently NM Mutual.

Responsibilities include reporting claims and providing information to NM Mutual;

N. Meeting federal employer requirements, such as completing and maintaining a federal I-9

form for each employee as required by law; and

O. When necessary, requesting assistance from the support broker and/or care coordinator

with any of these SDCB responsibilities.

SDCB SUPPORTS

In the SDCB, important resources of support and direction for SDCB members are the MCO, the Support

Broker and the FMA. The MCO determines initial and on-going medical eligibility, reviews and

authorizes the SDCB care plan/budget, and provides support to the SDCB member to ensure successful

implementation of the SDCB care plan. The Support Broker provides support to the SDCB member (or

the member’s family/representative, as appropriate) in arranging for, directing, and managing SDCB

services and supports as well as developing, implementing, and monitoring the SDCB care plan and

budget. The FMA acts as the intermediary between the SDCB member and the Medicaid payment system

and assists the SDCB member or the EOR with employer- related responsibilities.

1. Managed Care Organization

The MCO provides services related to medical eligibility determination and re- determination, and

determines the NFLOC for SDCB members. The MCO also performs utilization management

duties – review and approval or denial of each individual SDCB care plan. All SDCB members

have a care coordinator and a support broker. The care coordinator and support broker assist the

SDCB member with virtually every aspect of the SDCB. The support broker is instrumental in

developing the SDCB care plan and provides an additional layer of assistance to ensure successful

implementation of the SDCB care plan.

2. Care Coordinator

The care coordinator (CC) is responsible for managing the member’s acute care, behavioral health

care, long-term care, and home and community based services. In SDCB, the care coordinator is

primarily responsible for coordinating all aspects of the SDCB member’s care and for determining

the SDCB budget, and submitting the SDCB care plan to the MCO/UR for review and

approval/denial. SDCB CC related assistance includes, but is not limited to:

A. Understanding SDCB member and EOR roles and responsibilities;

B. Identifying resources outside the SDCB, including natural and informal supports, that may

assist in meeting the SDCB member’s needs;

C. Understanding the array of SDCB covered services, supports, and related goods;

D. Determining and assigning the annual budget for the SDCB member, based on the CNA, to

address the home and community based needs of the SDCB member in accordance with

the requirements stated in the managed care contract and the member’s Community

Benefit;

E. Providing the support broker with the current and all historical Comprehensive Needs

Assessments (CNA) including the Assessor’s individual specific health and safety

recommendations, and the calculations used to determine the SDCB budget;

F. Monitoring utilization of SDCB services and related goods on a regular basis;

G. Conducting employer-related activities such as completing the EOR self-assessment with

the member and informing the FMA of the designated EOR;

H. Identifying and resolving issues related to the implementation of the SDCB care

plan/budget;

I. Assisting the SDCB member with quality assurance activities to ensure implementation of

the SDCB member’s SDCB care plan/budget, and utilization of the authorized budget;

J. Recognizing and reporting critical incidents, including abuse, neglect, exploitation,

emergency services, law enforcement involvement, and environmental hazards;

K. Monitoring quality of services provided by support brokers; and

L. Working with the member to provide the necessary assistance for successful SDCB

implementation.

3. Support Broker

Support broker services are direct services intended to educate, guide, and assist the SDCB

member to make informed planning decisions about SDCB services and supports and to assist the

SDCB member with quality assurance related to the SDCB care plan. This leads to the

development of a SDCB care plan that is based on the SDCB member’s assessed needs and is in

accordance with 8.308.12 NMAC, and the Medical Assistance Division Managed Care Policy

Manual.

Support broker services help the SDCB member to identify supports, services and related goods

that meet his/her need for SDCB needs identified in the most recent CNA and are specific to the

member’s disability or qualifying condition and help prevent institutionalization. Support broker

services provide a level of support to SDCB members that are unique to their individual needs in

order to maximize their ability to self-direct in the SDCB.

A. The extent of assistance is based upon the individual SDCB member’s needs, and includes,

but is not limited to, providing help and guidance to:

a. Educate members on how to use self-directed supports and services and provide

information on program changes or updates;

b. Review, monitor and document progress of the member’s SDCB care plan;

c. Assist in managing budget expenditures and complete and submit SDCB care plan

revisions;

d. Assist with EOR functions including, but not limited to recruiting, hiring and

supervising SDCB providers;

e. Assist with developing job descriptions for the SDCB direct support caregivers;

f. Assist with completing forms related to SDCB employees;

g. Assist with approving timesheets and purchase orders or invoices for related goods,

obtaining quotes for services and related goods as well as identifying and

negotiating with vendors;

h. Assist with problem solving employee and vendor payment issues with the FMA

and other relevant parties;

i. Facilitate resolution of any disputes regarding payment to SDCB providers for

services rendered;

j. Develop the SDCB care plan based on the SDCB budget amount determined by

the annual CNA; and

k. Assist in completing all documentation required by the FMA.

B. Support broker services begin with the enrollment of the member in SDCB and continue

throughout the SDCB member’s participation in SDCB. The support broker shall:

a. Conduct a transition meeting, including the transfer of program information prior to

the SDCB enrollment meeting, for those members transitioning from the Agency

Based Community Benefit (ABCB);

b. Assist SDCB members to transition from/to ABCB/SDCB.

c. Provide the SDCB member with information, support and assistance during the

annual Medicaid eligibility processes, including the annual CNA and the annual

medical/financial eligibility processes;

d. Assist existing SDCB members with annual LOC requirements within ninety (120)

calendar days prior to the expiration of the LOC;

e. Schedule member enrollment meetings within five (5) business days of notification

and support broker agency selection. The actual enrollment meeting should be

conducted within 30 calendar days. Enrollment activities include but are not limited

to:

i. Ensure the member has received and reviewed the SDCB Rules and

Managed Care Policy Manual and provide responses to their questions

and/or concerns;

ii. General overview of the SDCB including key agencies, their

responsibilities and contact information;

iii. Discuss the annual Medicaid eligibility requirements and offer assistance in

completing these requirements as needed;

iv. Discuss and review SDCB member roles and responsibilities;

v. Discuss and review the EOR roles and responsibilities;

vi. Discuss and review the processes for hiring SDCB employees and

contractors and required paperwork;

vii. Discuss and review the process and paperwork for hiring Legally

Responsible Individuals ( LRI) as employees;

viii. Discuss and review the background check and other credentialing

requirements for SDCB employees and vendors; and

ix. Referral for accessing training for the FOCoSonline system; and to obtain

information on the Financial Management Agency (FMA).

f. Schedule the date for SDCB care plan meeting within 10 business days of the

SDCB enrollment meeting.

g. Provide information on the SDCB care plan including covered services and related

goods, planning tool and community resources available;

h. Assist the SDCB members in utilizing all program assessments including CNAN,

to develop each SDCB care plan;

i. Educate members regarding SDCB covered services, supports and related goods;

j. Assist SDCB member to identify resources outside SDCB that may assist in

meeting his/her needs as identified in the CNAN.

k. Assist the SDCB member with the application for LRI as employee process; submit

the application to the MCO/UR;

l. Assist SDCB members with the Environmental Modification process;

m. Serve as an advocate for the SDCB member, as needed, to enhance his/her

opportunity to be successful in the SDCB;

n. Assist the SDCB member with reconsiderations of services or related goods denied

by the MCO/UR, submit documentations as required, and participate in MCO

appeals process and State Fair Hearings as requested by the MCO, SDCB member

or state;

o. Assist the SDCB member with the quality assurance activities to ensure

implementation of the member’s SDCB care plan, and utilization of the SDCB

annual budget;

p. Assist SDCB members to transition to another support broker agency when

requested. Support Broker transitions should occur within 30 calendar days of

SDCB member’s written request, but may occur sooner based on the needs of the

SDCB member. Transition from one support broker agency to another can only

occur at the first of the month. Support broker agency transitions may not occur if

there are less than 120 days remaining in the current LOC; and

q. Assist SDCB members to identify and resolve issues related to the implementation

of the SDCB care plan.

C. Support Brokers must ensure that the SDCB care plan for each member is submitted in the

appropriate format as prescribed by the state, by using the FOCoSonline system.

a. The SDCB care plan in FOCoSonline shall include the following:

i. The requested services and supports that are covered by the SDCB, and

necessary to address the needs of the member as determined through the

CNA and person-centered planning process;

ii. The purpose for the requested services, expected outcomes, and methods

for monitoring progress must be clearly and specifically identified and

addressed;

iii. Clear, specific and accurate calculation of the employee/vendor

reimbursement rate including all local and/or federal taxes using the

calculator in FOCoSonline; and

iv. The quality indicators, identified by the member, for the services and

supports provided through the SDCB.SDCB care plan revisions shall be

completed and submitted as needed, in the format as prescribed by the state.

No more than one (1) revision is allowed to be submitted at any given time.

The annual SDCB care plan must be submitted to the care coordinator and

MCO/UR at least 30 calendar days prior to the expiration of the current

SDCB plan so that sufficient time is afforded for MCO/UR review. A copy

of the final approved SDCB care plan and budget documents must be

provided to each SDCB member.

D. Support brokers will contact the SDCB member in person or by telephone at least monthly

for a routine follow-up. Support brokers will meet in person with the member at least once

per quarter. It is mandatory that a minimum of one visit per SDCB care plan year is to be

conducted in the member’s home. Support brokers will, at a minimum:

a. Review spending patterns;

b. Review and document progress of SDCB care plan/budget implementation;

c. Document the usage and effectiveness of the SDCB backup plan; and

d. Document the purchase of related goods.

The quarterly visits are for the following purposes:

a. Review and document progress on implementation of the SDCB care plan;

b. Review and document any usage and the effectiveness of the 24-hour backup plan

and update the backup plan as necessary;

c. Review SDCB care plan and budget spending patterns (over and underutilization);

d. Review and document the SDCB member’s access to SDCB related goods

requested and approved in the SDCB care plan;

e. Review any incidents or events that have impacted the SDCB member’s health and

welfare or ability to fully access and utilize service(s) as identified and approved in

the SDCB care plan; and

f. Identify other concerns or challenges as noted by the member/representative/EOR.

E. Administrative Requirements

Support broker services may be provided by direct MCO personnel or by Support Broker

Agencies subcontracted by the MCO. SDCB members may choose to work with any

MCO-approved support broker agency in their region. If an MCO employs MCO

personnel to provide support broker services, the same qualifications and criteria that are

used for Support Broker Agencies also applies to the MCO personnel.

The support broker agency shall comply with all applicable federal, state rules, all policies

and procedures governing support broker services, all terms of their provider agreement

and shall meet all of the following requirements, as applicable:

a. Have a current business license issued by the state, county, or city government as

required;

b. Maintain financial solvency;

c. Ensure all employees providing support broker services under this standard attend

all state-required orientation and trainings and demonstrate knowledge of and

competence with the SDCB rules, policies and procedures, philosophy, including

self-direction, financial management processes and responsibilities, CNA, person-

centered planning and SDCB care plan development, and adhere to all other

training requirements as specified by the state;

d. Ensure that all employees are trained and competent in the use of the FMA and

FOCoSonline system;

e. Ensure all employees providing services under this scope of service and all other

staff are trained on how to identify and where to report critical incidents abuse,

neglect and exploitation; and

f. Ensure compliance with the Caregivers Criminal History Screening Requirements

(7.1.9 NMAC) for all employees.

g. The support broker agency shall develop a quality management plan to ensure

compliance with regulatory and program requirements and to identify opportunities

for continuous quality improvement.

The support broker agency shall ensure that SDCB members have access to their support

broker. This requirement includes, but is not limited to the following:

a. The support broker agency must maintain a presence in each region for which they

are providing services;

b. The support broker agency must maintain a consistent way (for example, phone,

pager, email, and fax) for the SDCB member to contact the support broker provider

during typical business hours which are 8:00 a.m. to 5:00 p.m. Monday through

Friday;

c. The support broker agency must maintain a consistent way (for example phone,

pager, email, and fax) for the SDCB member to contact the support broker provider

during non-business hours: prior to 8:00 a.m. and after 5:00 p.m. MST on

weekdays and on weekends and for emergency purposes;

d. The support broker agency must provide a location to conduct confidential

meetings with SDCB members when it is not possible to do so in the SDCB

member’s home. This location must be convenient for the SDCB member and

compliant with the Americans with Disabilities Act (ADA);

e. The support broker agency must maintain an operational fax machine at all times;

f. The support broker agency must maintain an operational email

g. address, internet access, and the necessary technology to access SDCB related

systems;

h. The support broker agency shall maintain a current local/state community resource

manual.

i. The support broker agency shall adhere to Medicaid General Provider policies

8.302.1.

j. The support broker agency shall ensure the development and implementation of a

written grievance procedure in compliance with 8.349.2.11 NMAC.

k. The support broker agency shall meet all of the qualifications set forth in 8.304.12

NMAC.

l. The support broker agency shall maintain HIPAA compliant primary records for

each SDCB member including, but not limited to:

i. Current and historical SDCB care plan and budget;

ii. Contact log that documents all communication with the SDCB member;

iii. Completed/signed quarterly visit form(s);

iv. MCO/UR documentation of approvals/denials, including SDCB care plan

and revision requests;

v. MCO/UR correspondence; (requests for additional information, etc.);

vi. Copy of current and all historical Comprehensive Needs Assessment (CNA)

including the Assessor’s individual specific health and safety

recommendations;

vii. Notifications of medical and financial eligibility;

viii. SDCB budget utilization reports from the FMA;

ix. Environmental Modification approvals/denials;

x. Responsible Individual (LRI) approvals/denials;

xi. Documentation of SDCB member and employee incident management

training;

xii. Copy of legal guardianship or representative papers and other pertinent

legal designations; and

xiii. Copy of the approval form for the authorized representative and/or

authorized agent.

F. Support Broker Qualifications

Support broker agencies shall ensure that all individuals providing support broker services

meet the criteria specified in this section.

a. Support broker providers shall:

i. Be at least 18 years of age;

ii. Possess a minimum of a Bachelor’s degree in social work, psychology,

human services, counseling, nursing, special education or a closely related

field;

iii. Have one (1) year of supervised experience working with seniors and/or

people living with disabilities;

iv. Complete all required SDCB orientation and training courses; and

v. Pass a nationwide caregiver criminal history screening pursuant to NMSA

1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen

pursuant to NMSA 1978, Section 27-7a-1 et seq. and 8.11.6 NMAC; or

b. Support broker providers shall:

i. Be at least 18 years of age;

ii. Have a minimum of six (6) years of direct experience related to the delivery

of social services to seniors and/or people living with disabilities;

iii. Be employed by an enrolled support broker agency or be employed by a

Centennial Care MCO ;

iv. Complete all required SDCB orientation and training courses; and

v. Pass a nationwide caregiver criminal history screening pursuant to NMSA

1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen

pursuant to NMSA 1978, Section 27-7a-1 et seq. and 8.11.6 NMAC.

G. Conflict of Interest

The support broker agency may not provide any other direct services for SDCB members

that have an approved SDCB care plan and are actively receiving services in the SDCB,

and the support broker agency may not employ, as a support broker, any immediate family

member or guardian of a member in the SDCB that is served by the support broker agency.

H. Critical Incident Management Responsibilities and Reporting Requirements

All incident reports for the Home and Community Based and Behavioral Health Services

population involving Abuse, Neglect, Self-Neglect, Exploitation, Environmental Hazard,

Law Enforcement Involvement, and Emergency Services, must be reported to the

member’s MCO, Support Broker and/or Adult Protective Services (APS).

a. The support broker agency shall provide training to SDCB members related to

recognizing and reporting critical incidents. Critical incidents include: abuse,

neglect, exploitation, emergency services, law enforcement involvement,

environmental hazards and member deaths. This SDCB member training shall also

include reporting procedures for SDCB employees, members/member

representatives, and other designated individuals. (Please refer to the Critical

Incident Management Responsibilities for requirements).

b. The support broker agency will also maintain documentation that each SDCB

member has been trained on the critical incident reporting process. This member

training shall include reporting procedures for SDCB members, employees,

member representative, and/or other designated individuals.

c. The support broker agency shall report incidents of abuse, neglect and/or

exploitation as directed by the state.

d. The support broker agency will maintain a critical incident management system to

identify, report, and address critical incidents. The support broker is responsible

for follow-up and assisting the individual to help ensure health and safety when a

critical incident has occurred.

4. Financial Management Agent

The Financial Management Agent (FMA) is under contract with the MCOs to provide payment for

SDCB services and related goods which are approved on the SDCB care plan.

A. The FMA is responsible for providing the following services in the SDCB:

a. Assure SDCB compliance with state and federal employment and IRS

requirements;

b. Assist each SDCB member/EOR to set up a unique Employer Identification

Number (EIN) if they intend to hire employees;

c. Answer member inquiries, solve related problems, and offer periodic trainings for

SDCB members and their representatives on how to handle the SDCB billing and

invoicing processes;

d. Provide all SDCB members with necessary documents, instructions and guidelines;

e. Collect all documentation necessary to verify that SDCB providers and vendors

have the qualifications and credentials required by the SDCB rules;

f. Collect all documentation necessary to support the SDCB member’s specific

arrangements with each employee and vendor, including employment agreement

forms and vendor agreement forms;

g. Successfully complete criminal history and/or background investigations for

prospective SDCB service providers, pursuant to 7.1.9 NMAC and in accordance

with 1978 Section 29-17-1 NMAC of the Caregivers Criminal History Screening

Act;

h. Check the Department of Health Employee Abuse Registry, pursuant to 7.1.12

NMAC Consolidated Online Registry (COR), to determine whether prospective

SDCB service providers or employees of SDCB members are included in the

registry. If a prospective SDCB provider or employee is listed in the Abuse

Registry, that person or vendor may not be employed by a SDCB member/EOR;

i. Process and pay invoices for SDCB services and related goods that are approved in

the SDCB member’s care plan, when supported by required documentation;

j. Handle all payroll functions on behalf of SDCB members who hire direct service

employees and other support personnel, including collecting and processing

timesheets of support workers, processing payroll, withholding, filing and payment

of applicable federal, state and local employment-related taxes and insurances;

k. Track and report on SDCB employee payment disbursements and balances of

SDCB member funds, including providing the SDCB member and his/her care

coordinator/support broker with a monthly report of expenditures and budget

status; and

l. Report any concerns related to the health and safety of a SDCB member or that the

SDCB member is not following the approved SDCB care plan/budget to the care

coordinator and/or support broker, and HSD/MAD, as appropriate.

B. FOCoSonline

a. In addition to the above functions, the FMA operates FOCoSonline. FOCoSonline

is a web-based system that is used for FMA functions such as housing the SDCB

care plan, noting the annual SDCB budget, tracking the credentialing status of

employees and vendors, timesheet submission, payment processing for employees

and vendors, and tracking the SDCB care plan/budget expenditures.

b. FOCoSonline is also used by SDCB members, support brokers and care

coordinators to develop and submit a SDCB care plan for MCO/UR review and

approval/denial.

c. The MCO/UR also uses FOCoSonline to receive SDCB care plan/budget requests

and request additional information from the SDCB member and care

coordinator/support broker, and to indicate what SDCB services, supports and

related goods have been approved or denied.

d. The FMA will provide SDCB members, care coordinators and support brokers with

training and access for FOCoSonline, as well as on-going technical assistance and

help with problem solving.

PLANNING AND BUDGETING FOR SDCB COVERED SERVICES

1. SDCB Care Plan Development Processes

The SDCB care plan development process starts with person-centered planning. In person-centered

planning, the SDCB care plan must revolve around the individual SDCB member and reflect

his/her chosen lifestyle, cultural, functional, and social needs for successful community living. The

goal of the SDCB care plan development process is for the SDCB member to achieve a meaningful

life in the community, as defined by the SDCB member. Upon enrollment in SDCB and choosing

his/her support broker agency, each SDCB member shall receive a SDCB budget amount, which is

determined by the care coordinator, based on the results of the NFLOC and the CNA. The SDCB

budget amount is entered into FOCoSonline by the care coordinator. The SDCB member will

receive information and training from the care coordinator and/or support broker about covered

SDCB services and the requirements for the content of the SDCB care plan.

The SDCB member is the leader in the development of the SDCB care plan. The SDCB member

will take the lead, or be encouraged and supported to take the lead to the best of his/her abilities, to

direct the development of the SDCB care plan. If the SDCB member desires, he/she may include

family members or other individuals, including service workers or providers, in the SDCB care

plan development process. The SDCB care plan is entered into FOCoSonline by the support

broker.

The SDCB care plan is developed one (1) goal at a time. Each goal shall include a clear and

complete explanation of the requested service(s) or good(s) as defined in the service description,

how they are related to the SDCB member’s condition and why they are appropriate for the SDCB

member.

In addition, each goal includes full details about each of the requested service(s) or good(s),

including, but not limited to: amount, frequency, cost or estimated cost, and rate of pay.

The SDCB care plan is developed by the SDCB member and the support broker. Once the SDCB

care plan request is complete and approved by the SDCB member, the support broker notifies the

care coordinator, via FOCoSonline, that the member’s SDCB care plan is ready for review and

submission into FOCoSonline. After reviewing the SDCB care plan, the care coordinator will

submit it in FOCoSonline to the MCO/UR for review and approval or denial using FOCoSonline.

Annual SDCB care plans shall be submitted by the care coordinator to the MCO/UR no later than

30 calendar days prior to the end of the current SDCB care plan/budget year. MCOs must provide

the SDCB member with a written notice of action for all MCO/UR decisions made in response to

SDCB service related requests made by the SDCB member via FOCoSonline.

2. SDCB Member’s Employer Authority

The SDCB EOR is the common-law employer of all SDCB service providers. The FMA serves as

the SDCB member’s agent in conducting payroll and other employer-related responsibilities that

are required by federal and state law.

3. SDCB Member Decision-Making Authority

SDCB members shall have authority to do the following:

A. Complete the employer paperwork to be submitted to the FMA;

B. Determine the amount paid for SDCB services within the State’s approved limits (Range

of Rates, Appendix C.);

C. Schedule the provision of SDCB services;

D. Specify service provider qualifications of the SDCB member’s choice, consistent with the

qualifications specified in the SDCB rules and the Managed Care Policy Manual;

E. Specify how SDCB services are provided, consistent with the SDCB rules and the

Managed Care Policy Manual;

F. Identify potential SDCB service providers and vendors and refer them to the FMA for

enrollment;

G. Arrange to have potential SDCB service providers paid for the approved SDCB services

by ensuring that all proposed SDCB employees and service providers complete all FMA

required paperwork, including a criminal background check when necessary. Payment for

approved SDCB services and related goods cannot be made until all necessary and required

paperwork is successfully completed and approved by the FMA;

H. Review, approve and submit SDCB provider timesheets to the FMA within established

timeframes. Timesheets may be submitted to the FMA by fax or through FOCoSonline.

Failure to submit SDCB provider timesheets within the required timeframes will result in

SDCB providers not being paid in accordance with the employee payroll schedule; and

I. Review, approve and submit payment requests, according to the SDCB care plan, for

approved SDCB services and related goods identified in the approved SDCB care plan.

The SDCB member/EOR must submit to the FMA a Purchase Request Form (PRF) and an

invoice or receipt from a SDCB vendor for any item he/she has an approved SDCB goal

and budget to purchase.

J. Additionally, the SDCB members:

a. Cannot/will not be reimbursed directly for any SDCB services, supports and/or

related goods;

b. Must follow the SDCB care plan as approved by the MCO/UR;

c. Shall work with the FMA to have all potential SDCB employees, providers and

vendors approved and enrolled prior to delivery or provision of any SDCB service

or good; and

d. Shall be accountable for the use of all SDCB funds.

SDCB QUALIFICATIONS FOR ALL SDCB EMPLOYEES, INDEPENDENT PROVIDERS,

PROVIDER AGENCIES AND VENDORS

In order to be approved as a SDCB employee, an independent provider, a provider

agency (excluding support broker agencies, which are covered later in this document) or a vendor, each

entity must meet the general and service specific qualifications found in the SDCB rules and Managed

Care Policy Manual, and submit an employee agreement packet or vendor agreement packet, specific to

the SDCB provider or vendor type, for approval to the FMA.

SDCB providers must meet all Federal and state requirements for home and community based providers.

In order to be an authorized provider for SDCB, and receive payment for delivered services, the potential

provider must complete and sign an employee agreement or vendor agreement and provide all required

credentialing documents. The potential provider’s credentials must be verified by the member/EOR and

the FMA.

1. General qualifications for SDCB individual employees, independent providers, including non-

licensed homemaker/companion workers and provider agencies who are employed by a SDCB

member/EOR to provide direct services:

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 SDCB member;

D. pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section

29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978,

Section 27-7a-1 et seq. and 8.11.6 NMAC;

E. complete training on critical incident, abuse, neglect, and exploitation reporting;

F. complete member specific training; the evaluation of training needs is determined by the

member or his/her legal representative; the member 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 SDCB member’s annual budget;

G. meet any other service specific qualifications, as specified in the SDCB rules (8.308.12

NMAC); and

H. maintain documentation of services provided per the SDCB rules (8.308.12 NMAC).

2. General qualifications for SDCB vendors, including those providing professional services:

A. be qualified to provide the service;

B. possess a valid business license, if applicable;

C. if a professional provider, be required to follow the applicable licensing regulations set

forth by the profession; refer to the appropriate New Mexico board of licensure for

information regarding applicable licenses;

D. if a support broker provider, meet all of the qualifications set forth in 8.308.12 NMAC;

E. if a currently approved SDCB provider, be in good standing with the appropriate state

agency;

F. meet any other service specific qualifications, as specified in the SDCB rules (8.308.12

NMAC); and

G. maintain documentation of services provided per the SDCB rules (8.308.12 NMAC).

3. General qualifications for Legally Responsible Individuals (LRIs) who provide services:

A. LRIs, e.g., the parent/guardian (biological, legal or adoptive) of a minor child (under age

18) or the guardian of a minor child, who must provide care to the child, or a spouse of a

SDCB member, may be hired and paid for the provision of SDCB covered services (except

support broker) under extraordinary circumstances in order to assure the health and welfare

of the member, to avoid institutionalization and provided that the state is eligible to receive

federal financial participation (FFP).

B. Extraordinary circumstances include the inability of the parent/legal guardian to find and

retain other qualified, suitable caregivers when the parent/guardian would otherwise be

absent from the home and, thus, the parent/guardian must stay at home to ensure the

member’s health and safety. The member may request that the LRI (parent/guardian or

spouse) be allowed to be employed by the SDCB member/EOR and provide SDCB

services as approved in the member’s current SDCB care plan. The request must include

documentation showing all attempts to employ other available resources in the member’s

community, the challenges the member and/or providers encountered, and why the

member-chosen providers were unable to successfully provide the approved SDCB

covered service as approved in the SDCB care plan.

C. 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. This

includes, but is not limited to, transportation of minors to and from school, activities and

events.

D. Requests to employ a LRI must be submitted in writing to the MCO. The request must be

approved or denied in writing by the appropriate MCO/UR staff member. The approval of

a LRI must be renewed annually, at the same time as the NFLOC and SDCB care plan.

E. Services provided by LRIs must:

a. meet the definition of a SDCB covered service and be specified in the member’s

approved SDCB care plan;

b. be provided by a SDCB member’s parent/guardian or spouse who meets the

provider qualifications and training standards specified in the SDCB rules and

these service descriptions and qualifications for that covered SDCB service; and

c. be paid at a rate that does not exceed the SDCB Range of Rates (Appendix C) for

the specific service the LRI is approved to provide, and be approved by the

MCO/UR.

SDCB COVERED SERVICES

1. All SDCB services are subject to the approval of the MCO/UR. Below is a list of SDCB covered

services and related goods for members in SDCB, followed by a detailed service description:

A. Behavior Support Consultation Services

B. Customized Community Support

C. Emergency Response

D. Employment Supports

E. Environmental Modifications

F. Home Health Aide

G. Homemaker/Direct Support

H. Nutritional Counseling

I. Private Duty Nursing

J. Related Goods

K. Respite

L. Skilled Therapy Services for Adults

M. Specialized Therapies

N. Transportation (Non-Medical)

2. Descriptions for each of the above SDCB covered services.

A. BEHAVIOR SUPPORT CONSULTATION SERVICES

a. Definition of Service

Behavior Support Consultation services consist of functional support assessments,

treatment plan development and training and support coordination for a SDCB

member related to behaviors that compromise a member’s quality of life. Behavior

Support Consultation services are provided in an integrated/natural setting or in a

clinical setting.

b. Scope of Services

i. Inform and guide the SDCB member, family, employees and/or vendors

toward understanding the contributing factors to the SDCB member’s

behavior;

ii. Identify support strategies to enhance functional capacities, adding to the

provider’s competency to predict, prevent and respond to interfering

behavior and potentially reducing interfering behaviors;

iii. Support effective implementation based on a functional assessment and

subsequent SDCB care plans;

iv. Collaborate with medical and ancillary therapies to promote coherent

psychotherapeutic medications; and

v. Monitor and adapt support strategies based on the response of the SDCB

member and his/her family, employees and/or vendors.

c. Behavior Support Consultant Qualifications – Individual:

i. Provide a tax identification number;

ii. Maintain a member file within HIPAA guidelines to include:

1. Member’s SDCB care plan;

2. Reports as requested in the SDCB care plan;

3. Contact notes; and

4. Training roster(s).

iii. Have and maintain a current New Mexico license with the appropriate

professional field licensing body; current licensure may be any of the

following:

1. Medical doctor (M.D.);

2. Licensed clinical psychologist;

3. Licensed psychologist associate (masters or PhD level);

4. Licensed social worker (LISW or LMSW);

5. Licensed professional clinical counselor (LPCC);

6. Licensed professional counselor (LPC);

7. Licensed psychiatric nurse (MSN/RNSC);

8. Licensed marriage and family therapist (LMFT); or

9. Licensed practicing art therapist (LPAT).

d. Behavior Support Consultant Qualifications - Provider Agency:

i. Provide a tax identification number; and current business license issued by

state, county or city government, if required.

ii. Maintain a member file within HIPAA guidelines to include:

1. Member’s SDCB care plan;

2. Reports as requested in the SDCB care plan;

3. Contact notes; and

4. Training roster(s).

iii. Ensure therapists have and maintain a current New Mexico license with the

appropriate professional field licensing body; current licensure may be any

of the following:

1. Medical doctor (M.D.);

2. Licensed clinical psychologist;

3. Licensed psychologist associate (masters or PhD level);

4. Licensed social worker (LISW or LMSW);

5. Licensed professional clinical counselor (LPCC);

6. Licensed professional counselor (LPC);

7. Licensed psychiatric nurse (MSN/RNSC);

8. Licensed marriage and family therapist (LMFT); or

9. Licensed practicing art therapist (LPAT).

B. CUSTOMIZED COMMUNITY SUPPORTS

a. Definition of Service

Customized Community Support Services are designed to offer the SDCB member

flexible supports that are related to the member’s qualifying condition or disability.

Customized Community Supports may include participation in congregate

community day programs and centers that offer functional meaningful activities

that assist with acquisition, retention, or improvement in self-help, socialization

and adaptive skills. Customized Community Supports may include adult day

habilitation, adult day health and other day support models. Customized

Community Supports are provided in community day program facilities and centers

and can take place in non-institutional and non-residential settings.

Customized Community Supports settings must be integrated and support full

access of individuals receiving Centennial Care Community Benefits to the greater

community, including opportunities to seek employment, and work in competitive

integrated settings, engage in community life, control personal resources, and

receive services in the community, with the same degree of access as individuals

not receiving Medicaid HCBS.

These services are provided at least four (4) or more hours per day one (1) or more

days per week as specified in the member’s SDCB care plan. Customized

Community Supports cannot duplicate or any other SDCB service.

b. Scope of Services

Customized Community Support services include, but are not limited to the

following:

ii. Provide supports in congregate and community day programs that assist

with the acquisition, retention or improvement in self-help, socialization

and adaptive skills;

iii. Adult day health services;

iv. Adult day habilitation services; and

v. Other day support model services.

c. Customized Community Supports Qualifications - Provider Agency:

i. Possess a current business license, if applicable;

ii. Meet financial solvency;

iii. Adhere to training requirements;

iv. Maintain member records for each member within HIPAA compliance;

v. Develop and adhere to a records management policy;

vi. Develop and adhere to quality assurance rules and requirements; and

vii. Adult day health provider agencies must be licensed by NM DOH as an

adult day care facility pursuant to 7.13.2 NMAC.

viii. Ensure all assigned staff meets the following qualifications:

1. Be at least 18 years of age;

2. Have at least one (1) year of experience working with people with

disabilities;

3. Be qualified to perform the service and demonstrate capacity to

perform required tasks;

4. Be able to communicate successfully with the member/member

representative;

5. Pass a nationwide caregiver criminal history screening pursuant to

NMSA 1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse

registry screen pursuant to NMSA 1978, Section 27-7a-1 et seq. and

8.11.6 NMAC;

6. Complete training on critical incident, abuse, neglect, and

exploitation reporting;

7. Complete member specific training; the evaluation of training needs

is determined by the member or his/her legal representative;

member is also responsible for providing and arranging for provider

training and supervising provider performance; training expenses for

paid providers cannot be paid for with the SDCB member’s budget;

and

8. Meet any other service qualifications, as specified in the SDCB

rules.

C. EMERGENCY RESPONSE

a. Definition of Service

Emergency Response services provide an electronic device that enables a member

to secure help in an emergency at home and thereby avoid institutionalization. The

member may also wear a portable “help” button to allow for mobility. The system

is connected to the member’s phone and programmed to signal a response center

when a “help” button is activated. The response center is staffed by trained

professionals.

b. Scope of Services

i. Testing and maintaining equipment;

ii. Training SDCB members, caregivers and first responders on the use of the

equipment;

iii. 24 hour monitoring for alarms;

iv. Checking systems monthly or more frequently if warranted

(e.g. electrical outages, severe weather); and

v. Reporting member’s condition that may affect service delivery.

vi. Initial set-up and installation of ERS devices is not a covered service; see

the service description for Environmental Modification for allowance of the

initial set-up and installation.

c. Emergency Response Qualifications – Vendor/Agency:

i. Comply with all laws, rules and regulations of the New Mexico State

Corporation Commission for Telecommunications and Security Systems;

and

ii. Comply with all laws, rules and regulations from the Federal Trade

Communication Commission (FCC) for telecommunications.

D. EMPLOYMENT SUPPORTS

a. Definition of Service

Employment Support services provide support to the member in achieving and

maintaining employment in jobs of his/her choice in his/her community. The

SDCB member must exhaust all available vocational rehabilitation supports prior

to requesting Employment Supports on his/her SDCB care plan Employment

Supports cannot duplicate any other SDCB service. Employment Supports include

two (2) types of services: job coaching and job-development. The specific

Employment Support service to be provided must be clearly described in the SDCB

member’s care plan and must address specific employment-related activities.

Employment Supports will be provided by staff at current or potential work sites.

If member is self-employed, Employment Supports may be provided in a setting

other than a formal work site. When Employment Support services are provided at

a work site where persons without disabilities are employed, payment is made only

for the adaptations, supervision and training required by members receiving SDCB

services as a result of their disabilities, but does not include payment for the

supervisory activities rendered as a normal part of the business setting.

Employment Supports settings must be integrated in, and support full access for

individuals receiving Medicaid HCBS to the greater community, including

opportunities to seek employment, and work in competitive integrated settings,

engage in community life, control personal resources, and receive services in the

community, to the same degree of access as individuals not receiving Centennial

Care Community Benefits.

Providers will maintain a confidential case file for each individual that documents

activities, progress and scope of work outlined in the member’s SDCB care plan.

Documentation is maintained in the file of each member receiving this service to

demonstrate that the service is not available under a program funded under section

110 of the Rehabilitation Act of 1973 or IDEA.

b. Employment supports include the following services:

i. Job Coaching: Job coaching is a service provided to members when the

services are not otherwise available for the member under a program funded

under the Rehabilitation Act of 1973, the Division of Vocational

Rehabilitation or through the New Mexico Department of Education. Job

coaching services are available 365 days a year, 24 hours a day. Services

are driven by the member’s SDCB care plan, budget and job. Medicaid

funds are not used to pay the member. Job coaches will adhere to the

specific supports and expectations negotiated with the member and

employer prior to service delivery.

ii. Job Development: Job development services are provided to SDCB

members when the services are not otherwise available for the member

under a program funded under the Rehabilitation Act of 1973, the Division

of Vocational Rehabilitation or through the New Mexico Department of

Education. Job development is a service provided to members by skilled

staff. The service has five (5) components: job identification and

development activities; employer negotiations; job restructuring; job

sampling; and job placement.

c. Scope of Job Coach Services

Job coach services will include, but are not limited to the following:

i. Provide support to members as contained in the SDCB care plan as to

achieve his/her outcomes;

ii. Teach vocational skills in a workplace setting;

iii. Employ job-coaching techniques and help SDCB members learn to

accomplish job tasks to the employer’s specifications;

iv. Increase the member’s capacity to engage in meaningful and productive

interpersonal interactions with co-workers, supervisors and customers;

v. Identify and strengthen natural supports that are available to the member at

the job site and decrease paid supports in response to increased natural

supports;

vi. Identify specific information about the member’s employment interests,

preferences and abilities;

vii. Effectively communicate with the employer about how to support the

member to succeed including any special precautions and considerations of

the member’s disability, medications, or other special concerns;

viii. Monitor and evaluate the effectiveness of the service and provide reports or

documentation to the member as requested in the SDCB care plan;

ix. Address behavioral, medical or other significant needs identified in the

SDCB care plan;

x. Follow any individual specific therapeutic recommendations including

speech, occupational and/or physical therapy, behavioral support, special

diets and other therapeutic routines that are noted in the SDCB care plan;

xi. Communicate effectively with the member including communication

through the use of adaptive equipment as well as the member’s

communication dictionary, if applicable, at the work site;

xii. Monitor the health and safety of the member;

xiii. Model behavior, instruct and monitor any work place requirements to the

member;

xiv. Adhere to professionally acceptable business attire and appearance, and

communicate professionally and in a respectful manner; and

xv. Adherence to rules of the specific work place, including dress,

confidentiality, safety rules and other areas required by the employer.

d. Scope of Job Development Services

i. Identify potential employers and jobs in the area that provide work

opportunities consistent with the member’s preferences, interests and

choice;

ii. Negotiate job functions, hours and supervision in the SDCB member’s best

interest;

iii. Conduct satisfaction surveys as requested by the SDCB member;

iv. Broker relationships between the employer and the SDCB member in order

to develop and maintain job success;

v. Identify potential employers and jobs in the area that provide work

opportunities consistent with the SDCB member’s preferences, interests and

choices;

vi. Conduct job task analysis to ensure appropriate job match(es);

vii. Assess barriers to SDCB member skill development on the job and provide

or obtain appropriate accommodations tailored to the SDCB member’s

ability to master task;

viii. Interact professionally in individual and group contacts, on the phone, in

writing with various levels of the company, including human resources and

management;

ix. Assist the employer with Americans with Disabilities Act (ADA) issues,

Work Opportunity Tax Credit (WOTC) eligibility, requests for reasonable

accommodations, disability awareness training and workplace modification

or make referrals to appropriate agencies;

x. Utilize, refer and communicate with the Division of Vocational

Rehabilitation (DVR) concerning job placement and referral activities

consistent with industry and SDCB standards;

xi. Utilize Department of Workforce Solutions (DWS) Navigators and One-

Stop Career Centers, , Business Leadership Network (BLN), Chamber of

Commerce, Job Accommodation Network (JAN), Small Business

Development Centers, Retired Executive, Businesses, community agencies,

and the NM Employment Institute to achieve employment outcomes;

xii. Maintain on-going communication with various levels of the employer

company to assure satisfaction to both the SDCB member and the company;

xiii. During the time of service delivery, ensure the SDCB member’s earnings

and benefits are in accordance with Fair Labor Standards Act (FLSA). Each

member’s earnings and benefits will be reviewed at least semi-annually

during the SDCB care plan year to ensure the appropriateness of pay rates

and benefits;

xiv. Conduct a vocational assessment or profile as deemed necessary upon

request of the member;

xv. Provide a career development plan as deemed necessary or upon the request

of the SDCB member;

xvi. Develop specific supports and expectations at the work site that are

appropriate to the setting and negotiated with the employer prior to and

during employment;

xvii. Verify and ensure that SDCB members receive job benefits and services

such as paid time off, health insurance, retirement, awards, raises,

performance reviews and training consistent with those in a similar job

category; and

xviii. Provide career and skill development for advancement and integration in

work-related activities or events.

e. Job Coach Qualifications – Individual Provider

i. Be at least 18 years of age;

ii. Be qualified to perform the service and demonstrate capacity to perform

required tasks;

iii. Be able to communicate successfully with the SDCB member;

iv. Experience as a job coach for at least (1) one year;

v. Experience for at least (1) one year using job and task analyses;

vi. Trained on American with Disabilities Act (ADA);

vii. Trained on the purpose, function and general practices of the Division of

Vocational Rehabilitation (DVR);

viii. Pass a nationwide caregiver criminal history screening pursuant to NMSA

1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen

pursuant to NMSA 1978, Section 27-7a-1 et seq. and 8.11.6 NMAC;

ix. Complete training on critical incident, abuse, neglect, and exploitation

reporting;

x. Complete SDCB member specific training; the evaluation of training needs

is determined by the SDCB member or his/her legal representative; SDCB

member is also responsible for providing and arranging for provider

training and supervising provider performance; training expenses for paid

providers cannot be paid for with the SDCB member’s annual budget; and

xi. Meet any other service qualifications, as specified in the SDCB rules.

f. Job Developer Qualifications – Individual Provider

i. Be at least 18 years of age;

ii. Pass criminal background check and abuse registry screen;

iii. Experience as a job developer for at least (1) one year;

iv. Experience for at least (1) one year developing and using job task and

analyses;

v. Experience for at least (1) one year working with the Division of Vocational

Rehabilitation, an independent living center or organization that provides

employment supports or services for people with disabilities;

vi. Trained on the purposes, functions and general practices entities such as:

1. Department of Workforce Solutions Navigators;

2. One-Stop Career Centers;

3. Business Leadership Network;

4. Chamber of Commerce;

5. Job Accommodation Network;

6. Small Business Development Centers;

7. Retired Executives; and

8. New Mexico Employment Institute.

vii. Pass a nationwide caregiver criminal history screening pursuant to NMSA

1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen

pursuant to NMSA 1978, Section 27-7a-1 et seq. and 8.11.6 NMAC;

viii. Complete training on critical incident, abuse, neglect, and exploitation

reporting;

ix. Complete member specific training; the evaluation of training needs is

determined by the member or his/her legal representative; member is also

responsible for providing and arranging for provider training and

supervising provider performance; training expenses for paid providers

cannot be paid for with the SDCB member’s annual budget; and

x. Meet any other service qualifications, as specified in the SDCB rules.

g. Job Coach and/or Job Developer Qualifications – Provider Agency

i. Possess a current business license, if applicable;

ii. Meet financial solvency;

iii. Adhere to training requirements;

iv. Maintain individual records for each member within HIPAA compliance.

The agency will maintain a confidential case file for each member that

documents activities, progress and scope of work outlined in the member’s

SDCB care plan;

v. Develop and adhere to a records management policy; and

vi. Develop and adhere to quality assurance rules and requirements.

vii. Ensure job coaches have the following qualifications:

1. Be at least 18 years of age;

2. Be qualified to perform the service and demonstrate capacity to

perform required tasks;

3. Be able to communicate successfully with the member;

4. Experience as a job coach for at least one year;

5. Experience for at least one year using job and task analyses;

6. Trained on American with Disabilities Act (ADA);

7. Trained on the purpose, function and general practices of the

Division of Vocational Rehabilitation (DVR);

8. Pass a nationwide caregiver criminal history screening pursuant to

NMSA 1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse

registry screen pursuant to NMSA 1978, Section 27-7a-1 et seq. and

8.11.6 NMAC;

9. Complete training on critical incident, abuse, neglect, and

exploitation reporting;

10. Complete member specific training; the evaluation of training needs

is determined by the member or his/her legal representative;

member is also responsible for providing and arranging for provider

training and supervising provider performance; training expenses for

paid providers cannot be paid for with the SDCB member’s annual

budget; and

11. Meet any other service qualifications, as specified in the SDCB

rules.

h. Ensure job developers have the following qualifications:

i. Be at least 18 years of age;

ii. Experience as a job developer for at least (1) one year;

iii. Experience for at least (1) one year developing and using job task and

analyses;

iv. Experience for at least (1) one year working with the Division of Vocational

Rehabilitation, an independent living center or organization that provides

employment supports or services for people with disabilities;

v. Trained on the purposes, functions and general practices entities such as:

1. Department of Workforce Solutions Navigators;

2. One-Stop Career Centers;

3. Business Leadership Network (BLN);

4. Chamber of Commerce;

5. Job Accommodation Network (JAN);

6. Small Business Development Centers;

7. Retired Executives; and

8. New Mexico employment institute.

vi. Pass a nationwide caregiver criminal history screening pursuant to NMSA

1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen

pursuant to NMSA 1978, Section 27-7

vii. a-1 et seq. and 8.11.6 NMAC;

viii. Complete training on critical incident, abuse, neglect, and exploitation

reporting;

ix. Complete SDCB member specific training; the evaluation of training needs

is determined by the SDCB member or his/her legal representative; SDCB

member is also responsible for providing and arranging for provider

training and supervising provider performance; training expenses for paid

SDCB providers cannot be paid for with the SDCB member’s annual

budget; and

x. Meet any other service qualifications, as specified in the SDCB rules.

E. ENVIRONMENTAL MODIFICATION

a. Definition of Service

Environmental Modification services include the purchase and/or installation of

equipment and/or making physical adaptations to a SDCB member's residence that

are necessary to ensure the health, welfare, and safety of the SDCB member or

enhance the SDCB member’s level of independence. All approved services shall

be provided in accordance with applicable federal, state, and local building codes.

The Environmental Modification provider must ensure proper design criteria is

addressed in the planning and design of the adaptation, provide or secure licensed

contractor(s) or approved vendor(s) to provide construction services, provide

administrative and technical oversight of construction projects, provide

consultation to family members, providers and contractors concerning

Environmental Modification projects to the SDCB member's residence, and inspect

the final Environmental Modification project to ensure that the adaptations meet

the approved plan submitted to the SDCB member’s care coordinator for

environmental adaptation.

Environmental Modifications are managed by professional staff available to

provide technical assistance and oversight to Environmental Modification projects.

All services shall be provided in accordance with applicable federal, state, and local

building codes.

b. Scope of Services

Environmental Adaptations include the following:

i. Installation of ramps and grab-bars;

ii. Widening of doorways/hallways;

iii. Installation of specialized electric and plumbing systems to accommodate

medical equipment and supplies;

iv. Installation of lifts/elevators;

v. Modification of bathroom facilities (roll-in showers, sink, bathtub, and

toilet modifications, water faucet controls, floor urinals and bidet

adaptations and plumbing);

vi. Turnaround space adaptations;

vii. Installation of specialized accessibility/safety adaptations/additions;

viii. Installation of Trapeze and mobility tracks for home ceilings;

ix. Installation of Automatic door openers/doorbells;

x. Installation of Voice-activated, light-activated, motion- activated and

electronic devices;

xi. Installation of Fire safety adaptations;

xii. Installation of Air filtering devices;

xiii. Installation of heating/cooling adaptations;

xiv. Installation of glass substitute for windows and doors;

xv. Installation of modified switches, outlets or environmental controls for

home devices; and

xvi. Installation of alarm and alert systems, emergency response systems, and/or

signaling devices.

c. Environmental Modification Qualifications – Individual Contractor and Agency

Contractor

i. Current business license;

ii. Appropriate plumbing, electrician, contractor license; and/or

iii. Appropriate technical certification or other license to perform the

modification.

d. The Environmental Modification provider must:

i. Provide a one (1)-year warranty from the completion date on all parts and

labor;

ii. Have a working knowledge of Environmental Modifications and be familiar

with the needs of persons with functional limitations in relation to

Environmental Modifications;

iii. Provide consultation to family members, providers and MCOs concerning

Environmental Modification projects to the SDCB member’s individual’s

residence, and inspect the final Environmental Modification project prior to

the member/EOR requesting the final payment to ensure that the

adaptations meet the approved plan as submitted and approved for

environmental adaptation; and

iv. Provider must establish and maintain financial reporting and accounting for

each member.

e. The Environmental Modification provider will submit the Environmental

Modification Service Cost Quote Packet containing the following information and

documentation to the MCO:

i. Environmental Modification evaluation;

ii. Service Cost Estimate. Drawings of the proposed modifications. The

estimated start date of the work on the proposed modification; (equipment,

materials, supplies, labor, travel, per diem, report writing time, and

completion date of modification);

iii. Letter of Acceptance of Service Cost Estimate signed by the SDCB

member/EOR;

iv. Letter of Permission from property owner. If the property owner is someone

other than the member, the letter must be signed by the property owner and

the member;

v. The Construction Letter of Understanding. If the property owner is

someone other than the member, the letter must be signed by the property

owner and the member; and

vi. Documentation demonstrating compliance with the Americans with

Disabilities Act (ADA).

f. The Environmental Modification provider must submit the following to the MCO,

after the completion of work:

i. Letter of Approval of Work completed signed by the SDCB member/EOR ;

ii. Photographs of the completed modifications.

g. The MCO must submit the following information to the provider:

i. Care Coordinator Individual Assessment of Need.

h. Reimbursement

Environmental Modification providers must maintain appropriate record keeping of

services provided, and fiscal accountability as indicated in the Medicaid Provider

Participation Agreement (MPPA). Billing is on a project basis, one (1) unit per

Environmental Modification project. Reimbursement for Environmental

Modification services will be based on the negotiated rate with the SDCB

member/EOR.

Environmental Modification services are limited to five thousand dollars

($5,000.00) every five (5) years, beginning from the first date of service.

Additional services may be requested if the member’s health and safety needs

exceed the specified limit. The $5,000.00 – five (5) year time limit applies across

all Community Benefit packages where Environmental Modifications are a covered

service. Example: an Agency Based Community Benefit (ABCB) member receives

an Environmental Modification of $2,300 leaving a $2,700 available balance for

future Environmental Modification. Six (6) months later the ABCB member

transitions to the Self-Directed Community Benefit (SDCB), the member now has

$2,700 available for Environmental Modifications.

Environmental Modifications excludes those adaptations or improvements to the

home that are of general utility and are not of direct medical or remedial benefit to

the member, such as carpeting, fences, roof repair, storage sheds or other

outbuildings, furnace replacement, insulation, and other general household repairs.

Adaptations that add to the total square footage of the home are also excluded from

this benefit except when necessary to complete an adaptation related to the SDCB

member’s medical condition.

F. HOME HEALTH AIDE

a. Definition of Service

Home Health Aide services provide total care or assist a SDCB member in all

activities of daily living. Home Health Aide services assist the SDCB member in a

manner that will promote and improve the SDCB member’s quality of life and

provide a safe environment for the SDCB member. Home health aide services can

be provided outside the SDCB member’s home.

State plan Home Health Aide services are intermittent and are provided primarily

on a short-term basis; whereas, in SDCB, Home Health Aide services are hourly

services for members who need this service on a more long-term basis.

Home Health Aides may provide basic non-invasive nursing assistant skills within

the scope of their practice. Home Health Aides do not administer medication(s),

adjust oxygen levels, perform any intravenous procedures or perform sterile

procedures. Home Health Aide services are not duplicative of homemaker/direct

support services.

b. Scope of Services

i. Provide personal hygiene (e.g. sponge bathing, showering, bed shampooing,

shaving, oral hygiene dressing);

ii. While under the supervision of a licensed physical therapist or licensed

nurse (RN or LPN), assist with ambulation, transfer and range of motion

exercises;

iii. Assist with menu planning, meal/snack preparation and assist member with

eating as necessary;

iv. As ordered by a physician and under supervision of a licensed nurse (RN or

LPN), he/she will assist with bowel and bladder elimination with activities

such as: catheter care, colostomy care, enemas, insertion of non-prescribed

suppository, prosthesis care and vital signs;

v. Provide homemaking services (e.g. laundry, linen change, cleaning);

vi. Pick up medication(s);

vii. Assist or prompt member in self administration of medication(s);

viii. Observe general condition of member and report changes to supervisor;

ix. Document SDCB member’s status and services furnished, infection control

procedures; and

x. Recognize emergencies and adhere to emergency procedures.

c. Home Health Aide Qualifications – Agency Provider

i. Licensed in New Mexico as a home health agency, rural health clinic or

federally qualified health center;

ii. Possess current business license;

iii. Meet financial solvency;

iv. Adhere to training requirements;

v. Maintain individual records for each SDCB member within HIPAA

compliance;

vi. Develop and adhere to records management policy; and

vii. Develop and adhere to quality assurance policies and processes.

viii. Supervision must be performed by a registered nurse. Such supervision

must occur at least once every 60 calendar days in the member's home, and

shall be in accordance with the New Mexico Nurse Practice Act and be

specific to the member's SDCB care plan. Contact must be made with

family members during supervision.

ix. Ensure all assigned staff meets the following qualifications:

1. Be at least 18 years of age;

2. Be qualified to perform the service and demonstrate capacity to

perform required tasks;

3. 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. Copies of Certified Nurse Aide (CNA)

certificates must be maintained in the personnel file of the home

health aide;

4. Be able to communicate successfully with the member;

5. Pass a nationwide caregiver criminal history screening pursuant to

NMSA 1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse

registry screen pursuant to NMSA 1978, Section 27-7a-1 et seq. and

8.11.6 NMAC;

6. Complete training on critical incident, abuse, neglect, and

exploitation reporting; and

7. Meet any other service qualifications, as specified in the SDCB

rules.

G. HOMEMAKER/DIRECT SUPPORT

a. Definition of Service

Homemaker or Direct Support services are provided on an episodic or continuing

basis to assist the SDCB member to accomplish tasks he/she would normally do for

him/herself if he/she did not have a disability. Homemaker or direct support

services are provided in the member’s home and in the community, depending on

the member’s needs. The SDCB member identifies the homemaker or direct

support worker’s training needs. If the SDCB member is unable to do the training

him/herself, the SDCB member arranges for the needed training.

Providers will bill for services in shared households within state guidelines. Two

(2) or more SDCB members living in the same residence, who are receiving

services and supports under SDCB will be assessed both independently and jointly

to determine coverage of services and supports that are shared. Services and

supports will be approved based on common needs and individual needs.

Services are not intended to replace supports available from a primary caregiver or

natural supports. Although a member’s assessment for the amount and types of

services may vary. Homemaker or Direct Support services are not provided 24

hours a day. Allocation of time and services must be directly related to an

individual’s functional level to perform ADLs and IADLs as indicated in the CNA.

This service is not available for members under age 21 because personal care

services are covered under the Medicaid state plan as expanded EPSDT benefits for

SDCB members under age 21.

b. Scope of Services

Homemaker/Direct Support Services include but are not limited to the following:

i. Assist the SDCB member with activities of daily living;

ii. Perform general household tasks, not including services such as yard

maintenance;

iii. Provide companionship to acquire, maintain or improve social interaction

skills in the community; and

iv. Attend trainings as designated by the SDCB member in the SDCB care

plan.

c. Homemaker/Direct Support Qualifications – Individual Provider

i. Be at least 18 years of age;

ii. Be qualified to perform the service and demonstrate capacity to perform

required tasks;

iii. Be able to communicate successfully with the SDCB member;

iv. Pass a nationwide caregiver criminal history screening pursuant to NMSA

1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen

pursuant to NMSA 1978, Section 27-7a-1 et seq. and 8.11.6 NMAC;

Complete training on critical incident, abuse, neglect, and exploitation

reporting;

v. Complete SDCB member specific training; the evaluation of training needs

is determined by the member or his/her legal representative; SDCB member

is also responsible for providing and arranging for provider training and

supervising provider performance; training expenses for ---paid providers

cannot be paid for with the SDCB member’s annual budget; and

vi. Meet any other service qualifications, as specified in the SDCB rules.

d. Homemaker/Direct Support Qualifications – Agency Provider

i. Home health agencies must hold a home health agency license;

ii. Possess a current business license, if applicable;

iii. Meet financial solvency;

iv. Adhere to training requirements;

v. Maintain individual records for each SDCB member within HIPAA

compliance;

vi. Develop and adhere to a records management policy; and

vii. Develop and adhere to quality assurance rules and requirements.

viii. Ensure all assigned staff meet the following qualifications:

1. Be at least 18 years of age;

2. Be qualified to perform the service and demonstrate capacity to

perform required tasks;

3. Be able to communicate successfully with the SDCB member;

4. Pass a nationwide caregiver criminal history screening pursuant to

NMSA 1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse

registry screening pursuant to NMSA 1978, Section 27-7a-1 et seq.

and 8.11.6 NMAC;

5. Complete training on critical incident, abuse, neglect, and

exploitation reporting;

6. Complete member specific training; the evaluation of training needs

is determined by the member or his/her legal representative;

member 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 SDCB

member’s annual budget; and

7. Meet any other service qualifications, as specified in the SDCB

rules and Managed Care Policy Manual.

H. NUTRITIONAL COUNSELING

a. Definition of Service

Nutritional Counseling services are designed to meet the unique food and

nutritional needs of SDCB members. This does not include oral-motor skill

development services, such as those provided by a speech pathologist.

b. Scope of Services

i. Assessment of nutritional needs;

ii. Development and/or revision of the SDCB member’s nutritional plan; and

iii. Counseling and nutritional intervention and observation and technical

assistance related to implementation of the nutritional plan.

c. Nutritional Counseling Qualifications - Individual Provider:

i. Be licensed per the New Mexico Regulation and Licensing Department;

Nutrition and Dietetics Practice Act, NMSA 1978, Section 61-7A et.seq.

d. Nutritional Counseling Qualifications - Agency Provider:

i. Current business license; and provide a tax identification number;

ii. Ensure staff meet the following qualifications:

iii. Licensed per the New Mexico Regulation and Licensing Department;

Nutrition and Dietetics Practice Act, NMSA 1978, Section 61-7A et.seq.

I. PRIVATE DUTY NURSING FOR ADULTS

a. Definition of Service

Private Duty Nursing for Adults services includes activities, procedures, and

treatment for a SDCB member’s physical condition, physical illness or chronic

disability. Children (individuals under the age of 21) receive this service through

the state plan Early and Periodic Screening, Diagnostic and Treatment (EPSDT).

b. Scope of Services

Private duty nursing services for adults may include performance, assistance and

education with the following tasks:

i. Medication management, administration and teaching;

ii. Aspiration precautions;

iii. Feeding tube management, gastrostomy and jejunostomy;

iv. Skin care;

v. Weight management;

vi. Urinary catheter management;

vii. Bowel and bladder care;Wound care;Health education and screening;

viii. Infection control;

ix. Environmental management for safety;

x. Nutrition management;

xi. Oxygen management;

xii. Seizure management and precautions;

xiii. Anxiety reduction;

xiv. Staff supervision; and

xv. Behavior and self-care assistance.

c. Private Duty Nursing Qualifications – Agency RIVATE DUTY NURSING

QUALIFICATIONS – AGENCY PROVIDER

i. Licensed in New Mexico as a Home Health Agency, Rural Health Clinic or

federally Qualified Health Center (FQHC Agency);

ii. Possess current business license;

iii. Meet financial solvency;

iv. Adhere to training requirements;

v. Maintain individual records for each member within HIPAA compliance;

vi. Develop and adhere to a records management policy; and

vii. Develop and adhere to quality assurance policies and processes.

viii. Ensure all assigned staff meet the following qualifications:

ix. Licensed by the New Mexico State Board of Nursing as a RN or LPN;

x. Demonstrate capacity to perform required tasks;

xi. Be able to communicate successfully with the member;

xii. Complete training on critical incident, abuse, neglect, and exploitation

reporting;

xiii. Individual RN/LPN providers must be licensed by the New Mexico state

board of nursing as an RN or LPN; and

xiv. Meet any other service qualifications, as specified in the SDCB rules.

d. Private Duty Nursing Qualifications – Individual RIVATE DUTY NURSING

QUALIFICATIONS – INDIVIDUAL PROVIDER

i. Provide a tax identification number;

ii. Individual RN/LPN providers must be licensed by the New Mexico State

Board of Nursing as an RN or LPN;

iii. Demonstrate capacity to perform required tasks;

iv. Be able to communicate successfully with the SDCB member;

v. Complete training on critical incident, abuse, neglect, and exploitation

reporting; and

vi. Meet any other service qualifications, as specified in the SDCB rules.

J. RELATED GOODS

a. Definition of Service

Related Goods are services, goods, and equipment, including supplies, fees or

memberships (such as for conferences or classes), which support the SDCB member

to remain in the community, decrease the need for other Medicaid services and

reduce the risk for institutionalization. Related goods must promote personal safety

and health, accommodate the SDCB member in managing his/her household and/or

facilitate activities of daily living. The related goods must not be available through

another source including the Medicaid state plan and/or Medicare, and the SDCB

member must not have the personal funds needed to purchase the goods.

Related goods must be documented in the SDCB care plan in a manner that clearly

describes how the related good will advance the desired outcomes in the SDCB

member’s care plan. Related goods must be linked to the SDCB member’s

identified needs and are intended for the sole use of the SDCB member, and one

caregiver, if appropriate. All related goods, must be approved by the MCO/UR. The

cost and type of related good is subject to approval by the MCO/UR. SDCB

members are not guaranteed the exact type and model of related good that is

requested. The support broker and/or the care coordinator can work with the SDCB

member to find other (including less costly) alternatives. Items that are purchased

with SDCB funds cannot be returned for store credit, cash or gift cards.

Experimental or prohibited treatments and related goods are excluded.

b. Scope of Services

Related Goods must address a specific, assessed need identified in the member’s

CNA (including improving and maintaining the member’s opportunities for full

membership in the community) and must directly relate to the SDCB member’s

qualifying condition or disability. Related goods must explicitly address the SDCB

member’s clinical functional, medical or habilitative needs.

Related Goods must meet all of the following requirements:

i. Are related to a need or goal identified in the approved care plan;

ii. Are for the purpose of increasing independence or substituting for human

assistance, to the extent the expenditures would otherwise be made for that

human assistance;

iii. Promote opportunities for community living and inclusion;

iv. Are able to be accommodated within the member’s budget without

compromising the member’s health or safety; and

v. Are provided to, or directed exclusively toward, the benefit of the member.

c. Medicaid does not pay for the purchase of related goods or services that a

household not including a person with a disability would be expected to pay for as

a routine household or personal expense. Examples include, but are not limited to:

i. Goods or services that are considered primarily recreational or diversional;

ii. Cell phones and cell phone service for SDCB members who are minors

(these are items that legally responsible individuals such as a

parent/guardian, or spouse would ordinarily purchase for household

members of the same age who do not have a disability or chronic illness);

iii. Cell phone services including fees for data and GPS in excess of $100 per

month or more than one cell phone per SDCB member;

iii.iv. Cell phone services that include more than one cell phone or cell phone line

per SDCB member; cell phone service, including data, is limited to the cost

of one hundred dollars per month;

iv.v. Room and board, meaning shelter expenses (including property-related

costs such as home and property maintenance, insurance policies, utilities

and all deposits; and all food items other than nutritional supplements as

approved in the SDCB care plan);

v.vi. Purchase of usual and customary furniture/home furnishings,

vi.vii. Regularly scheduled upkeep, maintenance and repairs of a home, addition

of fences, insulation, construction of storage sheds or other outbuildings,

except upkeep and maintenance of modifications or alterations to a home

which are an accommodation directly related to the SDCB member’s

qualifying condition or disability;

vii.viii. Regularly scheduled upkeep, maintenance and repairs of a vehicle or van,

or tire purchase or replacement, except upkeep and maintenance of

modifications or alterations to a vehicle or van, which is an accommodation

directly related to the SDCB member’s qualifying condition or disability.

viii.ix. Purchase, lease, or rental of a vehicle, including recreational vehicles;

ix.x. Memberships/fees related to religious activities/events;

x.xi. Purchase of animals and the costs of maintaining animals, including the

purchase of food, veterinary visits, grooming and boarding but with the

exception of training and certification for service dogs;

xi.xii. Purchase of insurance policies, such as automobile, health, life, burial,

renter’s, home-owner, service warrantees or other such policies, including

the purchase of cell phone insurance;

xii.xiii. Personal goods or items not related to the SDCB member’s qualifying

condition or disability, including clothing and personal hygiene products

and accessories;

xiii.xiv. Moving expenses including but not limited to the cost of moving truck

rental, gas/mileage, labor, storage, moving equipment and supplies;

xiv.xv. Vacation expenses, including means of transport, guided tours, meals, tips,

lodging or similar recreational expenses including fuel, mileage or driver

time reimbursement for vacation travel by an automobile;

xv.xvi. Costs associated with conferences or classes, including airfare, lodging,

mileage/gas, or meals;

xvi.xvii. Training expenses for employees;

xvii.xviii. Professional housecleaning or yard maintenance;

xviii.xix. Formal academic degrees or certification-seeking education, educational

services covered by IDEA, or vocational training provided by the public

education department (PED), division of vocational rehabilitation (DVR);

and

xix.xx. For electronics such as cell phones, computers (including desktop, laptop,

and tablets), monitors, printers and fax machines, copiers, and other

electronic equipment, no more than one of each type of item may be

purchased at one (1) time, and member electronics may not be replaced

more frequently than once every three (3) years.

d. Related Goods Qualifications - Vendor Agency Provider:

i. Valid tax identification for the state and federal governments.

K. RESPITE

a. Definition of Service

Respite is to be used to give the primary caregiver a break on an episodic basis in

the event of an emergency or to prevent burnout.Respite is a flexible family

support service that provides support to the SDCB member and allows the primary

unpaid caregiver time away from his/her duties. Respite services are used to allow

the SDCB member’s unpaid primary caregiver a limited leave of absence in order

to reduce stress, accommodate caregiver illness, or meet a sudden family crisis or

emergency, therefore the primary unpaid caregiver may not be the paid Respite

provider. R e s p i t e p r o v i d e s a t e m p o r a r y r e l i e f t o t h e

p r i m a r y c a r e g i v e r o f a S D C B m e m b e r d u r i n g t i m e s

w h e n t h e c a r e g i v e r w o u l d n o r m a l l y p r o v i d e u n p a i d

c a r e . Respite services are furnished on a short term basis and can be provided

in the SDCB member’s home, the provider’s home, in community setting of the

family’s choice (e.g., community center, swimming pool and park, or at a center in

which other individuals are provided care).

Respite services may be provided by eligible individual respite providers; licensed

registered (RN) or practical nurses (LPN); or respite provider agencies.

b. Scope of Services

Respite services include, but are not limited to the following:

i. For members meeting NFLOC, respite services are limited to a maximum

of 100 hours annually per care plan year provided there is a primary unpaid

providercaregiver. The 100 hour Respite service applies across all

community benefit packages where Respite is a covered service.

Additional hours may be requested if an eligible beneficiary’s health and

safety needs exceed the specified limit.

ii. Assist with routine activities of daily living (e.g. bathing, toileting,

preparing or assisting with meal preparation and eating);

iii. Enhance self-help skills, leisure time skills and community and social

awareness;

iv. Provide opportunities for leisure, play and other recreational activities;

v. Provide opportunities for community and neighborhood integration and

involvement;

vi. Provide opportunities for the SDCB member to make his/her own choices

with regards to daily activities.

vii. Respite services do not include the cost of room and board;

viii. Cannot be used for purposes of day-care; and

ix. Cannot be provided to school age children during school hours.

c. Respite Qualifications – Individual Provider

i. Be at least 18 years of age;

ii. Be qualified to perform the service and demonstrate capacity to perform

required tasks;

iii. Be able to communicate successfully with the SDCB member;

iv. Pass a nationwide caregiver criminal history screening pursuant to NMSA

1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen

pursuant to NMSA 1978, Section 27-7a-1 et seq. and 8.11.6 NMAC;

v. Complete training on critical incident, abuse, neglect, and exploitation

reporting;

vi. Complete member specific training; the evaluation of training needs is

determined by the member or his/her legal representative; member is also

responsible for providing and arranging for provider training and

supervising provider performance; training expenses for paid providers

cannot be paid for with the SDCB member’s annual budget;

vii. Meet any other service qualifications, as specified in the SDCB rules and

Managed Care Policy Manual; and

viii. Individual RN/LPN providers must be licensed by the New Mexico State

Board of Nursing as an RN or LPN.

d. Respite Qualifications - Provider Agency

i. Possess a current business license, if applicable;

ii. Meet financial solvency;

iii. Adhere to training requirements;

iv. Maintain individual records for each SDCB member within HIPAA

compliance;

v. Develop and adhere to a records management policy; and

vi. Develop and adhere to quality assurance rules and requirements.

vii. Ensure all assigned staff meet the following qualifications:

1. Be at least 18 years of age;

2. Be qualified to perform the service and demonstrate capacity to

perform required tasks;

3. Be able to communicate successfully with the SDCB member;

4. Pass a nationwide caregiver criminal history screening pursuant to

NMSA 1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse

registry screen pursuant to NMSA 1978, Section 27-7a-1 et seq. and

8.11.6 NMAC;

5. Complete training on critical incident, abuse, neglect, and

exploitation reporting;

6. Complete SDCB member specific training; the evaluation of

training needs is determined by the SDCB member or his/her legal

representative; member is also responsible for providing and

arranging for provider training and supervising provider

performance; training expenses for paid providers cannot be paid for

with the SDCB member’s SDBC annual budget;

7. Individual RN/LPN providers must be licensed by the New Mexico

State Board of Nursing as an RN or LPN; and

8. Meet any other service qualifications, as specified in the SDCB

rules and Managed Care Policy Manual.

L. SKILLED MAINTENANCE THERAPIES SERVICES

a. Definition of Service

Skilled Maintenance Therapies are provided when Medicaid state plan skilled

therapy services are exhausted. Adult members in SDCB access therapy

services under the Medicaid state plan for acute and temporary conditions that

are expected to improve significantly in a reasonable and generally predictable

period of time. A signed therapy referral for treatment must be obtained from the

SDCB member’s primary care physician. The referral will include frequency,

estimated duration of therapy, and treatment/procedures to be rendered. Therapy

services provided to adults in SDCB are to focus on health maintenance,

improving functional independence, community integration, socialization,

exercise or to enhance supports and normalization of family relationships.

i. Physical Therapy is the diagnosis and management of movement

dysfunction and the enhancement of physical and functional abilities.

ii. Occupational Therapy is the diagnosis, assessment and management of

functional limitations intended to assist adults to regain, maintain, develop

and build skills that are important for independence, functioning and health.

iii. Speech Language Therapy services preserve speech fluency, voice, verbal,

written language, auditory comprehension, cognition, swallowing

dysfunction, oral pharyngeal or laryngeal and sensor motor competencies.

Speech Language Pathology is also used when a SDCB member requires

the use of an augmentative communication device. Based upon therapy

goals, services may be delivered in an integrated natural setting, clinical

setting or in a group.

b. Scope of Services

i. Physical Therapy:

1. Diagnostic activities to determine the dysfunction of physical and

functional activities;

2. Activities to increase, maintain or reduce the loss of functional

skills;

3. Treat specific condition(s) clinically related an SDCB member’s

qualifying condition or disability;

4. Activities to support the SDCB member’s health and safety needs;

and

5. Identify, implement and train on therapeutic strategies to support the

SDCB member, family and/or staff in the home setting or other

environments as addressed in the SDCB care plan.

ii. Occupational Therapy

1. Diagnostic activities to determine skills assessment and treatment;

2. Write treatment program to improve one’s ability to perform daily

tasks;

3. Comprehensive home, employment and/or volunteer sites

evaluations with adaptation recommendations;

4. Provide guidance to family members and caregivers;

5. Make assistive technology recommendations and provide usage

training for SDCB members, family and staff; and

6. Identify, implement and train on therapeutic strategies to support the

SDCB member, family and/or staff in the home setting or other

environments as addressed in the SDCB care plan.

iii. Speech and Language Pathology

1. Improve or maintain the SDCB member’s capacity for successful

communication or to lessen the effects of the member’s loss of

communication skills;

2. Consultation on usage and training on augmentative communication

devices;

3. Activities to improve or maintain the SDCB member’s ability to eat

food, drink liquid and manage oral secretions with minimal risk of

aspiration or other injuries or illness related to swallowing disorders;

and

4. Activities to identify, implement, and train on therapeutic strategies

to support the SDCB member, his/her family and/or staff consistent

with the member’s SDCB care plan.

iv. Therapy Qualifications – Individual Therapist Provider

1. Provide a tax identification number.

2. Maintain a case file within HIPAA guidelines for the SDCB

member to include:

a. SDCB member’s SDCB care plan;

b. Reports as requested in the SDCB care plan;

c. Contact notes;

d. Training roster(s); and

e. Assessments for Environmental Modification requests.

3. Licensures:

a. Physical therapists will be licensed as per the New Mexico

Regulation and Licensing Department; Physical Therapy Act

NMSA 1978, Section 61-12-1.1 et.seq;

b. Occupational therapists will be licensed as per the New

Mexico Regulation and Licensing Department; Occupational

Therapy Act NMSA 1978, Section 61-12A- 1et.seq.; and

c. Speech and Language Pathologists will be licensed as per the

New Mexico Regulation and Licensing Department;

Occupational Therapy Act NMSA 1978, Section 61-14B-

1et.seq.

v. Therapy Qualifications – Provider Agency

1. Current business license;

2. Provide tax identification number;

3. Ensure physical therapists maintain a case file within HIPAA

guidelines for the SDCB member to include:

a. SDCB member’s SDCB care plan;

b. Reports as requested in the SDCB care plan;

c. Contact notes;

d. Training roster(s); and

e. for Environmental Modification requests.

4. Ensure therapists has appropriate license for service

a. Physical therapists will be licensed as per the New Mexico

Regulation and Licensing Department; Physical Therapy Act

NMSA 1978, Section 61-12-1.1 et.seq.;

b. Occupational therapists will be licensed as per the New

Mexico Regulation and

c. Licensing Department; Occupational Therapy Act NMSA

1978, Section 61-12A- 1et.seq.; and

d. Speech and Language Pathologists will be licensed as per the

New Mexico Regulation and Licensing Department;

Occupational Therapy Act NMSA 1978, Section 61-14B-

1et.seq.

M. SPECIALIZED THERAPIES SERVICES

a. Definition of Service

Specialized Therapies are non-experimental therapies or techniques that have been

proven effective for certain conditions. Services must be related to the SDCB

member’s disability or condition, and ensure the SDCB member’s health and

welfare in the community. The service will supplement to (not replace) the SDCB

member’s natural supports and other community services for which the SDCB

member may be eligible.

Experimental or investigational procedures, technologies or therapies and those

services covered in Medicaid state plans are excluded.

Only the specific specialized therapy services outlined below are covered in the

SDCB.

b. Scope of Services:

i. Acupuncture is a distinct system of primary health care.

The goal of acupuncture is to prevent, cure or correct any disease, illness,

injury, pain or other physical or mental condition by controlling and

regulating the flow and balance of energy, form and function to restore and

maintain physical health and increased mental clarity. Acupuncture may

provide effective pain control, decreased symptoms of stress, improved

circulation and a stronger immune system, as well as other benefits. See

Acupuncture and Oriental Medicine Practitioners 16.2.1 NMAC.

ii. Biofeedback uses visual, auditory or other monitors to provide SDCB

members physiological information of which they are normally unaware.

This technique enables a SDCB member to learn how to change

physiological, psychological and behavioral responses for the purposes of

improving emotional, behavioral and cognitive health performance.

Biofeedback may assist in strengthening or gaining conscious control over

the above processes in order to self-regulate. Biofeedback is also useful for

muscle re- education of specific muscle groups or for treating pathological

muscle abnormalities of spasticity, incapacitating muscle spasm or

weakness.

iii. Chiropractic care is designed to locate and remove interference with the

transmissions or expression of nerve forces in the human body by the

correction of misalignments or subluxations of the vertebral column and

pelvis. Chiropractic care restores and maintains health for treatment of

human disease primarily by, but not limited to adjustment and manipulation

of the human structure. Chiropractic therapy may positively affect

neurological function, improve certain reflexes and sensations, and increase

range of motion and lead to improved general health. See

Chiropractitioners 16.4.1 NMAC.

iv. Cognitive rehabilitation therapy is designed to improve cognitive

functioning with the following activities: reinforcing, strengthening, or re-

establishing previously learned patterns of behavior; establishing new

patterns of cognitive activity; or compensatory mechanisms of impaired

neurological systems. Treatments may be focused on improving a

particular cognitive domain such as attention, memory, language, or

executive functions. Alternatively, treatments may be skill-based, aimed at

improving performance of activities of daily living. The overall goal is to

restore function in a cognitive domain or set of domains or to teach

compensatory strategies to overcome specific cognitive problems.

v. Hippotherapy is a physical, occupational and speech- language therapy

treatment strategy that utilizes equine movement as part of an integrated

intervention program to achieve functional outcomes. Hippotherapy applies

multidimensional movement of a horse for members with movement

dysfunction and may increase mobility and rage of motion, decrease

contractures and aid in normalizing muscle tone. Hippotherapy requires

that the member use cognitive functioning especially for sequencing and

memory. Members with attention deficits and behavior problems are

redirecting attention and behaviors by focusing on the activity.

Hippotherapy involves therapeutic exercise, neuromuscular education,

kinetic activities, therapeutic activities, sensory integration activities and

individual speech therapy. The activities may also help improve respiratory

function and assist with improved breathing and speech production.

vi. Massage therapy is the assessment and treatment of soft tissues and their

dysfunction for therapeutic purposes primarily for comfort and relief of

pain. It includes gliding, kneading, percussion, compression, vibration,

friction, nerve strokes, stretching the tissue and exercising range of motion

and may include the use of oils, salt glows, hot or cold packs or

hydrotherapy. Massage increases the circulation, helps loosen contracted,

shortened muscles and can stimulate weak muscles to improve posture and

movement, improves range of motion and reduces spasticity. Massage

therapy may increase, or help sustain, a member’s ability to be more

independent in the performance of activities of daily living; thereby,

decreasing dependency upon others to perform or assist with basic daily

activities. See Massage Therapists 16.7.1 NMAC.

vii. Naprapathy focuses on the evaluation and treatment of neuro-

musculoskeletal conditions and is a system for restoring functionality and

reducing pain in muscles and joints. The therapy uses manipulation and

mobilization of the spine and joints and muscle treatments such as

stretching and massage. Based on the concept that constricted connective

tissue (ligaments, muscles and tendons) interfere with nerve, blood and

lymph flow, naprapathy uses manipulation of connective tissue to open

these channels of body function. See Naprapathic Practitioners 16.6.1

NMAC.

viii. Native American healing therapies encompass a wide variety of

culturally-appropriate therapies that support members in their communities

by addressing their physical, emotional and spiritual health. Treatments

may include prayer, dance, ceremony and song, plant medicines and foods,

participation in sweat lodges, and the use of meaningful symbols of healing,

such as the medicine wheel and/or other sacred objects.

c. Specialized Therapy Qualifications – Individual Therapist Provider

i. Current New Mexico state license as applicable:

1. Acupuncture and Oriental Medicine license

2. Biofeedback – license in a healthcare profession whose scope of

practice includes biofeedback, and appropriate specialized training

and clinical experience and supervision.

3. Chiropractic Physician license

4. Cognitive rehabilitation therapy – license in a health care profession

whose scope of practice includes cognitive rehabilitation therapy,

and appropriate specialized training and clinical experience and

supervision.

5. Hippotherapy – license in a health care profession whose scope of

practice includes hippotherapy and appropriate specialized training

and experience.

6. Massage therapy license

7. Naprapathic Physician license

8. Native American Healers – individuals who are recognized as

healers within their communities. This form of therapy may be

provided by community-recognized medicine men and women and

others as healers, mentors and advisors to SDCB members.

d. Specialized Therapy Qualifications - Provider Agency

1. Current business license; and

2. Provide tax identification number

3. Group practice/vendor staff must hold current New Mexico

licensure and training in their respective discipline as follows:

a. Acupuncture and Oriental Medicine license

b. Biofeedback – license in a healthcare profession whose

scope of practice includes biofeedback, and appropriate

specialized training and clinical experience and supervision.

c. Chiropractic Physician license

d. Cognitive rehabilitation therapy – license in a health care

profession whose scope of practice includes cognitive

rehabilitation therapy, and appropriate specialized training

and clinical experience and supervision.

e. Hippotherapy – license in a health care profession whose

scope of practice includes hippotherapy and appropriate

specialized training and experience.

f. Massage therapy license

g. Naprapathic Physician license

h. Native American Healers – individuals who are recognized

as healers within their communities.

N. TRANSPORTATION (NON-MEDICAL)

a. Definition of Service

Transportation services are offered in order to enable SDCB members to gain

access to and from other community services, activities and resources, as specified

by the SDCB care plan. Transportation services are intended for access to the

member’s local area, within a 75 mile radius of the SDCB member’s home.

Transportation services under SDCB are non-medical in nature, whereas

transportation services provided under the Medicaid state plan are to transport

members to medically necessary physical and behavioral health services.

Transportation for the purpose of picking up pharmacy prescriptions is allowed.

Transportation for the purpose of vacation is not covered through the SDCB.

Non-medical transportation services for minors is not a covered service as these are

services that a LRI would ordinarily provide for household members of the same

age who do not have a disability or chronic illness.

Transportation is reimbursed in three (3) different ways to the driver: by the mile;

by the trip; or at an hourly rate. It may also be paid through the purchase of a bus

pass or local taxi. Payments are made to the SDCB member’s individual

transportation employee or vendor or to a public or private transportation service

vendor. Payments cannot be made to the SDCB member. Whenever possible,

natural supports should provide this service without charge.

b. Scope of Services

The service will be provided as specified in the SDCB member’s SDCB care plan.

SDCB transportation services cannot be used instead of, or to replace,

transportation services available under the Medicaid state plan.

Payment of transportation services cannot be made to legally responsible

individuals (parent/guardian, or spouse) who would ordinarily provide

transportation for household members of the same age who do not have a disability

or chronic illness. Payment is allowable for transportation to and from specific

locations/sites that provide specific services that are approved in the member’s care

plan goals.

c. Transportation Qualifications - Individual Provider

i. Be at least 18 years of age;

ii. Possess a valid New Mexico driver’s license;

iii. Be free of physical or mental impairment that would adversely affect

driving performance;

iv. No driving while intoxicated (DWI) convictions within the previous two (2)

years;

v. No chargeable (at fault) accidents within the previous two (2) years;

vi. Have current CPR/First Aid certification;

vii. Complete training on critical incident, abuse, neglect, and exploitation

reporting; and

viii. Possess and maintain current insurance policy and registration.

d. Transportation Qualifications – Provider Agency

i. Current business license;

ii. Valid tax identification number;

iii. Have a current basic First Aid kit in the vehicle;

iv. Each vehicle will contain a current insurance policy and registration; and

v. Ensure drivers meet individual qualifications:

1. Be at least 18 years of age;

2. Possess a valid New Mexico driver’s license;

3. Be free of physical or mental impairment that would adversely

affect driving performance

4. No driving while intoxicated (DWI) convictions within the previous

two (2) years;

5. No chargeable (at fault) accidents within the previous two (2) years;

6. Have current CPR/First Aid certification;

7. Complete training on critical incident, abuse, neglect, and

exploitation reporting;

8. Trained on New Mexico Department of Health Improvement (DHI)

Critical Incident Reporting and Procedures; and

9. Possess current insurance policy and registration.

SELF-DIRECTED NON-COVERED SERVICES

When a SDCB member requests a non-covered service or good, the support broker and/or care

coordinator shall work with the member to find other (including less costly) alternatives. Services and

goods that are not covered by the SDCB program include, but are not limited to:

1. Services covered by third-parties. The SDCB Program is the payer of last resort;

2. Any service or good, the provision of which would violate federal or state statutes, rules or

guidance. This includes services that are considered primarily recreational or diversional, which

are not deemed eligible SDCB services by CMS.

SDCB BUDGET AND CARE PLAN APPROVAL PROCESSES

Initial Member Entry into FOCoSonline and Working Plan

The care coordinator adds the member to FOCoSonline when the member has expressed a desire to

transfer to SDCB by signing the SDCB statement. Once the member selects the support broker agency

he/she wishes to work with, the care coordinator informs the support broker agency of the selection. After

the support broker meets with the member and an anticipated transfer date is agreed upon, the support

broker creates a Working Plan shell with the anticipated SDCB care plan dates. Once the Working Plan

shell is created, the care coordinator shall enter the SDCB budget amount in FOCoSonline.

INITIAL SDCB BUDGET DETERMINATION PROCESS

The SDCB budget is determined by the care coordinator and is based on two (2) factors: the needs

identified in the CNA, and the amount and type of services the member has been receiving in the ABCB.

The care coordinator shall review the existing ABCB services and calculate a dollar amount for the

services, using the approved ABCB reimbursement schedule. The care coordinator shall also review the

needs identified in the CNA. Both of these evaluations are used to assign the SDCB budget amount to be

used to develop the SDCB care plan. The care coordinator shall provide the support broker with the

SDCB budget amount.

The member must receive his/her home and community based services in the ABCB for a minimum of

120 calendar days before transferring to the SDCB. The initial 12-month SDCB budget shall be pro-rated

based on the number of months already completed in the ABCB. The SDCB member may request a new

CNA if the SDCB member thinks his/her needs were not adequately addressed in the initial CNA.

INITIAL SDCB CARE PLAN APPROVAL PROCESS

Once the SDCB care plan is developed, the support broker, in cooperation with the SDCB member, shall

inform the care coordinator that the SDCB care plan is ready for review. Once the care coordinator

reviews the SDCB care plan, the care coordinator shall formally submit the SDCB care plan in

FOCoSonline to the MCO/UR for review and approval/denial decisions. The SDCB member’s SDCB

care plan must be reviewed and each individual requested goal approved or denied by the MCO/UR and

written notification must be sent to the SDCB member before any SDCB services may be utilized and

related goods may be purchased. If, during the process of reviewing the SDCB care plan and all

subsequent SDCB care plan revisions, the MCO/UR is unable to make a decision on a goal, due to

insufficient information, the MCO/UR shall initiate a “Request For (additional) Information” (RFI) via

FOCoSonline. The MCO/UR shall provide written notification to the SDCB member and the support

broker, specifying what is needed by the MCO/UR to satisfy the RFI. It is the SDCB member’s

responsibility to provide a timely and complete response to the RFI. The support broker/care coordinator

may assist the SDCB member in obtaining the requested documents to fulfill the RFI. Member/support

broker must provide the RFI response to the care coordinator within 15 calendar days from the date of the

RFI letter. After review of the RFI response the care coordinator shall submit the RFI response to the

MCO/UR for approval/denial decision. If the requested information is not received by the care

coordinator within 15 calendar days from the date of the RFI letter, the service or good shall be denied by

the MCO/UR.

If the care coordinator or MCO/UR identifies an administrative error on the submitted SDCB care plan a

“Request for Administrative Action” (RFA) shall be sent to the support broker. The RFA shall specify

what is needed to correct the administrative error. The support broker must respond to the RFA within

five (5) calendar days from the date of the RFA notification. If the RFA is not addressed by the support

broker or care coordinator within five (5) calendar days from the date of the RFA letter, the service or

good shall be denied by the MCO/UR

The MCO/UR will notify the SDCB member, care coordinator, and support broker in writing when a

determination has been made on the SDCB care plan. The determination may be a full approval, a partial

approval, or a full denial. The MCO/UR shall indicate which goal(s) of the SDCB care plan have been

approved or denied in FOCoSonline. Written notifications will include steps for the SDCB member/legal

representative to follow if the member disagrees with a denial decision.

The FMA will utilize the approved SDCB care plan/budget to process payment for the approved amount

of SDCB services and related goods.

The SDCB member’s SDCB care plan must be approved before SDCB services can begin. The MCO

will not issue payment for any SDCB services, supports and/or related goods which are provided or

purchased prior to the approval of the SDCB care plan, or before the provider is linked to the SDCB care

plan.

At the earliest opportunity, the SDCB care plan and the NFLOC shall be aligned to start/end on the same

day. This may entail truncating the existing SDCB care plan to align with the annual NFLOC, or

truncating the existing NFLOC to align with the annual SDCB care plan.

ANNUAL SDCB BUDGET DETERMINATION AND APPROVAL PROCESS

Approximately 90 calendar days prior to the expiration of the existing SDCB care plan/budget, the Care

Coordinator shall conduct the annual CNA. The Care Coordinator shall assign the SDCB budget based

on the assessed needs identified in the CNA. The SDCB budget is determined annually and the budget

amount may differ from year to year. The SDCB budget shall not be higher than the cost of care for

persons served in a private nursing facility, unless the member transitioned into SDCB with their prior

approved self-directed budget. Unused budget from a previous year cannot be carried over to the new

SDCB care plan year.

Approximately 90 days prior to the expiration of the existing SDCB care plan/budget, the support broker

shall open the new Working Plan shell in FOCoSonline, with the begin and end dates for the upcoming

SDCB care plan. Upon the annual SDCB budget determination, the care coordinator shall enter the SDCB

budget amount in FOCoSonline, allowing the member and support broker to begin developing the

upcoming year’s SDCB care plan.

ANNUAL SDCB CARE PLAN DEVELOPMENT AND APPROVAL PROCESS

At a minimum, the SDCB care plan must be developed and submitted to the MCO/UR for review

annually, and no less than 30 calendar days prior to the expiration of the existing SDCB care plan/budget.

This 30-calendar day timeframe allows enough time for the care coordinator and MCO/UR to make an

informed and accurate determination of all requested SDCB services before the existing SDCB care

plan/budget expires. The MCO/UR will notify the SDCB member, care coordinator, and support broker in

writing when a determination has been made on the SDCB care plan request. The determination may be a

full approval, a partial approval, or a full denial. The MCO/UR shall indicate which goal(s) of the SDCB

care plan have been approved or denied in FOCoSonline and a letter shall be sent to the member

including written instructions for the member/legal representative to follow if the member disagrees with

the denial decision(s).

SDCB BUDGET AND CARE PLAN APPROVAL PROCESS FOR INDIVIDUALS WHO

TRANSITIONED (GRANDFATHERED) FROM THE MI VIA WAIVER PROGRAM

Prior to 1/1/2014, the Mi Via TPA approved many Mi Via employees/vendors at a reimbursement rate

which was above the maximum Mi Via rate for a particular Mi Via service. The high reimbursement rate

is to continue to be approved in SDCB so long as the specific EOR and SDCB provider relationship does

not encounter a break in service. If, for any reason, the relationship ends and a new employee/vendor is

hired, the SDCB reimbursement rate for the new SDCB provider shall not exceed the current approved

SDCB range of rates (Appendix C) for any SDCB covered service. When the aforementioned situation

occurs, the budget may be reduced by the corresponding amount if the SDCB member has no other

legitimate SDCB need(s).

Although Related Goods are not a covered service in ABCB, the need for ‘continuity of care’ exists for

Related Goods. When redetermining the annual SDCB budget for SDCB members who transitioned from

the Mi Via waiver program, the MCO CC/UM shall allow the currently approved.

rRelated Ggood(s) and previously approved reimbursement rate to be requested and approved, as deemed

appropriate, for each ongoing year of the SDCB care plan/budget. These amounts shall be added to the

SDCB budget of the assessed ABCB services.

At each annual assessment and budget determination, the care coordinator shall determine if the SDCB

member has underutilized his/her current SDCB care plan/budget. Underutilization is defined as using

less than 75 percent of the total budget by the end of quarter three of the SDCB member’s current care

plan year. If underutilization has occurred, the care coordinator shall consider reducing the budget by an

amount which is no more than the approved total for the underutilized SDCB service for the upcoming

SDCB care plan year/budget. However, if underutilization is due to, for example, a temporary hospital

admission, and if the hospital admission had not occurred, the member would have utilized SDCB

services as requested and approved, the Care Coordinator may not adjust the SDCB budget for the

upcoming SDCB care plan year/budget.

If overutilization of the SDCB care plan/budget is identified at any time during the SDCB care

plan/budget year, the MCO shall not increase the current SDCB budget without identifying the need for a

new CNA, and determining whether all other available resources have been exhausted prior to requesting

additional service(s) through the SDCB. Overutilization is defined as using more than 1) 50 percent of the

SDCB budget by the end of quarter two of the SDCB member’s current care plan year, 2) 75 percent of

the SDCB budget by the end of quarter three of the SDCB member’s current care plan year, or 3) 100

percent of the SDCB budget by the end of quarter four of the SDCB member’s current care plan year.

Underutilization and overutilization of the SDCB budget may result in an involuntary termination from

the SDCB to ABCB depending on the situation; please refer to the SDCB involuntary termination policy.

DENIALS, REVISIONS AND RECONSIDERATIONS OF THE SDCB CARE PLAN

1. Denials

The MCO/UR shall send final decisions to the SDCB member in writing, including steps for the

member/legal representative to follow if he/she disagrees with the denial decision and wants to

pursue a reconsideration and/or the MCO appeal process. The MCO appeal process must be

exhausted prior to the member requesting a State Fair Hearing.

2. Revisions

The SDCB care plan may be revised based upon a change in the member’s needs or circumstances

identified in the CNA, such as a change in the member’s health status or condition, or a change in

the member’s natural support system such as the death or disabling condition of a family member

or other individual who was providing services.

If the revision is to provide new or additional services other than those originally included in the

SDCB care plan, these services must not be able to be acquired through other programs or sources.

The SDCB member may be required to document the fact that the services are not available

through another source. The care coordinator and/or support broker shall assist the SDCB

member with exploring other available resources.

The SDCB member must provide written documentation of the change in needs or circumstances

as specified in the Managed Care Policy Manual. The SDCB member submits the documentation

to the care coordinator/support broker. In FOCoSonline the member’s legal representative and the

support broker initiate the process to modify the SDCB care plan by developing a revision in

FOCOSonline and forwarding the completed request for a SDCB care plan revision to the care

coordinator who will submit the revision to the MCO/UR for review, via FOCoSonline. At the

MCO’s discretion, another CNA may be performed. Per the SDCB rule, if the revision includes a

request for additional services, another CNA must be performed to determine whether the change

in needs or circumstances necessitate an increase to the SDCB budget.

The SDCB care plan may be revised once the original SDCB care plan has been submitted and

approved. Only one (1) SDCB care plan revision may be submitted at a time, for example, a

SDCB care plan revision may not be submitted if an initial SDCB care plan or prior SDCB care

plan revision request is under initial review by the MCO/UR.

Other than for critical health and safety reasons, SDCB care plan revision requests may not be

submitted to the MCO/UR within the last 60 calendar days prior to the expiration date of the

current SDCB care plan/budget. This constraint does not apply to Environmental Modifications

requests, as the Environmental Modification work is not tied to a specific SDCB care plan year

and the funding is not part of the overall SDCB budget amount.

Anytime a SDCB member exits SDCB and transfers to ABCB or is permanently institutionalized,

the support broker must develop a close-out budget to coincide with the last day the member will

receive SDCB services. The only time a close-out budget is not needed is when a member’s care

plan will expire in the same month as the member’s final month in SDCB. The close-out budget

must be reviewed/approved by the MCO-UR.

3. Reconsiderations

If the SDCB care plan, or a part of the SDCB care plan, is not approved/denied, the care

coordinator and/or support broker assists the SDCB member to explore his/her options, including

the right to request a reconsideration of the denial decision. Reconsideration requests must be

submitted to the MCO/UR within 30-calendar days of the date on the denial notice.

Reconsideration requests must be made by the support broker inside FOCoSonline, and additional

documentation or additional clarifying information must be submitted in writing, regarding the

SDCB member’s request for reconsideration of the denied SDCB services or related goods.

SDCB CARE PLAN REVIEW CRITERIA

Services and related goods identified in the SDCB member’s requested SDCB care plan may be

considered for approval if all the following requirements are met:

1. The SDCB services or related goods must be responsive and directly related to the SDCB

member’s qualifying condition or disability; and

2. The SDCB services or related goods must address the SDCB member’s clinical, functional,

medical or habilitative needs; and

3. The SDCB services or related goods must accommodate the SDCB member in managing his/her

household; and

4. The SDCB services or related goods must facilitate activities of daily living; and

5. The SDCB services or related goods must promote the SDCB member’s personal health and

safety; and

6. The SDCB services or related goods must afford the SDCB member an accommodation for

greater independence; and

7. The SDCB services or related goods must support the SDCB member to remain in the community

and reduce his/her risk for institutionalization; and

8. The SDCB services or related goods must be documented in the SDCB member’s SDCB care plan

and facilitate the desired outcomes stated in the SDCB member’s SDCB care plan; and

9. The SDCB service or related good is not prohibited by federal and state statutes, rules and

guidance; and

10. Each SDCB service or good must be listed as an individual line item; when services or related

goods must be ‘bundled’ the SDCB care plan must document why bundling is necessary and

appropriate; and

11. The proposed SDCB care plan is within the SDCB member’s approved budget; and

12. The proposed rate for each SDCB service is within the SDCB range of rates (Appendix C) for that

chosen service; and

13. The proposed cost for each SDCB good is reasonable, appropriate and reflects the lowest available

cost for that chosen good; and

14. The estimated cost of the SDCB service or good is specifically documented in the SDCB

member’s SDCB care plan.

IMPLEMENTATION OF THE SDCB CARE PLAN

1. Enrolling SDCB Employees and Vendors

A. Pre Hire Packet

Before providing SDCB services to a SDCB member, most employees and vendors are

required to submit the appropriate state approved pre-hire packet to the FMA and pass the

Consolidated On-Line Registry (COR) screening. The exception to this requirement is

when the vendor has a professional license, such as a registered nurse or SLP that qualifies

them to provide the approved service. The FMA is responsible for maintaining,

distributing and processing the pre-hire packets. For answers to questions about hiring

employees or vendors and to obtain the pre- hire packet, an EOR shall contact the FMA

Help Desk.

Potential SDCB employees are required by NM law through the caregivers’ criminal

history screening act (7.1.9 NMAC) to pass a criminal background check (CBC) which

begins by screening against the COR. This COR screening is completed by the FMA,

usually within 48 hours, once the complete and correct pre-hire packet is received by the

FMA. Once the COR check is completed, and the potential SDCB provider has passed the

COR check, the EOR will receive an e-mail notification from the FMA that the potential

SDCB employee has passed his/her COR and CBC and may begin providing SDCB

services. If the EOR does not have an e-mail address listed in FOCoSonline, the FMA

Help Desk will contact the EOR, via telephone to let the EOR know that the potential

SDCB employee has passed the COR check. Although an employee may begin providing

services as soon as he/she has passed the COR Background Check, payment will not be

issued until all required paperwork as indicated below is successfully completed and has

been approved by the FMA. If a potential SDCB employee or vendor does not pass the

CBC, as required by NM law, he/she may not continue to provide services to the SDCB

member. The potential SDCB employee or vendor and FMA will be notified by the

Department of Health if he/she does not pass the CBC. The FMA will notify the SDCB

member/EOR when a potential SDCB employee has or has not successfully completed the

COR check and/or CBC.

No SDCB provider shall exceed 40 hours paid work in one (1) work week per EOR. If an

employee works for more than one EOR, the employee shall not exceed 40 hours paid

work in one (1) work week, per EOR.

B. Credentialing Requirements

The State has set credentialing requirements for credentialing providers of SDCB services,

and these requirements have been approved by the Centers for Medicare and Medicaid

Services (CMS). The FMA shall ensure that these requirements are met. These

requirements include certain licenses which must be submitted by the potential SDCB

provider to the FMA, and are described in Appendix D & E (Vendor and Employee

Credentialing Requirements).Services cannot be provided to a member until the SDCB

care plan is approved, and there is a credentialed and approved provider linked to the

approved SDCB goal. Other Required

C. Other Required Documents

There are other documents that must be correctly completed by the potential SDCB

employee or vendor, and submitted to the FMA for review and approval before payment

can be made. Potential SDCB employees and vendors may obtain these documents may

be obtained by contacting the FMA. It is the member/EOR’s responsibility to ensure all

employment documents are submitted to the FMA.

D. For potential SDCB employees, the required documents are included in the Employee

Packet:

a. Employment Agreement

b. Employee Information Form

c. Declaration of Relationship form

d. Federal W-4

e. State W-4

E. For potential SDCB vendors who are providing services the required documents are

included as part of the Vendor Packet:

a. Vendor Agreement

b. Vendor Information Form

c. Federal W-9

F. Vendors who are providing SDCB related goods only (such as a large retailer) do not need

to provide the Vendor Agreement and Federal W-9, however the SDCB member/EOR or

vendor must submit the Vendor Information Form to the FMA before payment is issued.

G. Direct Deposit is provided and strongly recommended for all employees and vendors when

possible. The FMA also offers the service of providing payment through a ComData Card.

Please contact the FMA if interested in using this service. Direct deposit forms can be

completed as part of the initial hire documentation, or may be completed and submitted to

the FMA at a later date.

2. Purchasing Services and Related Goods

A. Timesheets

With access to the FOCoSonline system, a SDCB employee (or EOR) may enter the

employee(s)’s timesheet(s) in FOCoSonline. The EOR may then review and approve the

timesheet through online access. Having access to FOCoSonline and submitting

timesheets online means that the EOR or employees do not need to send the paper

timesheet to the FMA for processing. Upon completing the FOCoSonline training, a new

user will receive a FOCoSonline Account Authorization form (via e-mail). Once the new

user completes the FOCoSonline Account Authorization form and faxes it to the FMA

Technical Department, the user will receive an e-mail with his/her password and login

instructions. Timesheets may also be mailed or faxed to the FMA if the SDCB member of

EOR does not have access to a computer or the internet.

Timesheets are submitted and processed on a two-week pay schedule according to the

SDCB Payroll Payment Schedule. The payroll workweek starts on Saturday and ends the

following Friday. The payment schedule is available through the FMA and on the MCOs’

websites. Timesheets are due at the end of the two- week pay period and must be received

at the FMA no later than Saturday at 11:59 pm for a SDCB employee to be paid on time

and according to the payment schedule.

An Authorized Representative (AR) may also complete the training and gain access to

FOCoSonline. If an AR has access, they will be able to view payments and monitor SDCB

budget spending, however, the AR will not have authorization to perform the functions of

the EOR and approve timesheets. To designate an AR, members must complete the AR

Form, which may be requested through the FMA or the support broker.

B. Invoices

Vendor Payment Request Forms (PRF) (Appendix F) and invoices may be submitted to the

FMA on any day of the week (unlike timesheets which must be submitted according to the

payroll schedule). The processing time for a PRF/invoice is approximately two (2) weeks.

The vendor payment schedule is available through the FMA. Vendor checks are generated

by TeleCheck and are mailed directly to the EOR (payments are not mailed to the vendor).

After the EOR receives the vendor check, it is recommended that the EOR mail the check

to the vendor as soon as possible to ensure prompt payment. For phone/internet payments,

the EOR must send the payment to the phone/internet company’s main billing address

(with the payment coupon). It is not recommended that phone/internet payments be

attempted through kiosks or at local phone/internet stores (e.g., T-Mobile or Cricket) since

these payments are frequently rejected by TeleCheck.

Although an EOR may submit timesheets online (after completing necessary FOCoSonline

training and paperwork), it is not possible to submit invoices online. PRFs and invoices

must be faxed or sent electronically to the FMA for processing. However, Iif a SDCB

member/EOR has access to FOCoSonline, he/she may review his/her payments and

monitor them as they are being processed. In addition, the SDCB member, EOR, or AR

may run reports through FOCoSonline to monitor spending activity.

C. Return to Member Process

Return-to-Member (RTM) letters are an effective means used by the FMA to assist in

communicating with the EOR when there are problems in processing SDCB payment. For

example, if a timesheet or invoice is submitted to the FMA and it does not contain the

appropriate signatures, the FMA uses the RTM process to inform the EOR that payment

cannot be made. In addition to the RTM letter which is mailed, the FMA attempts contact

with the EOR by phone. If three (3) unsuccessful phone call attempts to the EOR have

been made and the corrected document still has not been received, the FMA will send an e-

mail to the EOR (provided the EOR has an e-mail address in FOCoSonline) with a copy to

the care coordinator and support broker. If the EOR does not have an e-mail address in

FOCoSonline, the FMA will send an e-mail to the care coordinator and support broker and

attach a copy of the RTM letter. Since frequent contact is attempted by the FMA to the

EOR, it is extremely important that FOCoSonline contain the EOR’s correct contact

information. If the EOR contact information needs to be updated, please contact the FMA

Help Desk for assistance.

D. Employee and Vendor Pay Rates

Employee and vendor pay rates must be approved in the SDCB member’s SDCB care

plan. Once the SDCB rate is approved, completed employee agreements and vendor

agreements must be submitted to the FMA in order to indicate the rate of pay. If a potential

SDCB employee or vendor does not submit an Employee or Vendor agreement, as

appropriate, the FMA will not know the correct rate of pay for the service that the

employee or vendor is providing. In order for the FMA to pay a SDCB employee or

vendor, a complete employee agreement or vendor agreement needs to be submitted to,

and approved by, the FMA and the employee/vendor must be linked to the SDCB goal

inside FOCoSonline. If the pay rate for an approved SDCB employee or vendor needs to

be changed, the new rate must be approved by the MCO via a SDCB care plan revision in

FOCoSonline and in the SDCB member’s SDCB care plan and a new employee agreement

or vendor agreement, signed by the EOR, must be submitted to the FMA at least 15

calendar days before the effective date of the rate change. If a change to a SDCB

employee’s rate of pay is made after the SDCB care plan has started, the change will not

be effective until the beginning of the next pay period.

E. Timely-Filing Requirements

New Mexico has a 90-calendar day time limit for filing all Medicaid claims and since the

SDCB is a Medicaid benefit, the same requirements apply. If timesheets or invoices are

submitted more than 90 calendar days after the service has been provided, payment will

not be processed and the timesheet or invoice and PRF will be returned to the

EOR/Member through the RTM process.

3. SDCB Care Plan Expenditure Safeguards

The SDCB member holds the primary responsibility for monitoring and ensuring that his/her

approved SDCB care plan is spent appropriately; however, the care coordinator and support

broker must support the SDCB member in this activity. The FMA also assists in ensuring that

funds are spent appropriately through payment of approved services and related goods according

to the approved SDCB care plan and Employee/Vendor Agreements.

The SDCB member is responsible for reviewing his/her monthly spending report which is mailed

to each SDCB member/legal representative by the FMA on a monthly basis. The SDCB member

may also obtain “real-time” information on service usage and spending by directly accessing

FOCoSonline. It is highly recommended that SDCB members obtain access to FOCoSonline so

that they can effectively monitor their SDCB care plan/budget and track spending. In addition, the

EOR and employees may obtain access to FOCoSonline. With FOCoSonline access, the EOR

will have the capability to approve timesheets that an employee has entered online. Monthly

training for FOCoSonline is offered for SDCB members, employees, and EORs. If interested in

training, the SDCB member, employee, or EOR may contact the FMA Help Desk for assistance.

The support broker is required to review the SDCB member’s SDCB care plan expenditures

during each quarterly face-to-face contact with the SDCB member. The care coordinator and/or

support broker will provide the SDCB member with expenditure information and discuss any

concerns. If the SDCB member needs to revise his/her SDCB care plan, the support broker shall

assist with drafting the revision and the care coordinator will submit it to the MCO/UR for

consideration per established procedures. The care coordinator may also initiate a new CNA as

needed.

The FMA is responsible for processing payments for approved SDCB services and related goods.

When an invoice or timesheet is received by the FMA, they verify that the particular service or

good is approved in the SDCB member’s SDCB care plan/budget and payment is processed

according to the approved SDCB care plan/budget and employee/vendor agreement. In regards to

internet and phone services (landline or cell), the FMA will pay up to the approved monthly

amount. This helps to ensure that this category of service is not overspent which could put the

SDCB member at-risk of losing these services due to possible non-payment later in the SDCB

care plan year. If the FMA is unable to make payment as requested due to lack of funds remaining

in the SDCB care plan, the FMA will send a return to member (RTM) letter to the SDCB member

and make three (3) attempts to contact the SDCB member by telephone to inform the

EOR/member of the insufficient funds issue.

TRANSITIONS, TERMINATION AND REINSTATEMENT PROCESSES

1. Community Benefit Transitions

Upon initial eligibility for the Community Benefit, the member will be eligible for the Agency

Based Community Benefit (ABCB). An ABCB member may choose to move to SDCB at any

time but may not move to SDCB until the first day of the month after 120 calendar days are

completed in the ABCB. The member must always end the current community benefit on the last

day of the month and start the new community benefit on the first day of the following month.

The care coordinator must ensure there is no break in Community Benefit services. If the member

has a short term admission, for example 2 weeks, the 120 days does not start over.

Examples of transition include, but are not limited to, the following:

A. The member only has a waiver COE (090, 091, 092, 093 or 094) and is institutionalized

more than 60 days, the member must apply for IC and submit their name back on the

Central Registry. They then must receive a Community Reintegration allocation. If,

when they are discharged, they still have living arrangements in place, they are not

required to complete the 120 days again.

B. If the member does not have living arrangements in place, the member must go back to

ABCB during the transition and is not mandated to complete another 120 day in ABCB.

Meaning, the member can begin self-directing after all living arrangements have been set

up and the member is successfully in that living arrangement and the SDCB budget, care

plan and employees are approved to provide SDCB covered services.

C. If the member has a full Medicaid COE (001, 003, 004, etc.) and is institutionalized for

more than 60 days and the member does not have living arrangements still in place, the

member must go back to ABCB during the transition and is not mandated to complete

another 120 day. Meaning, the member can begin self-directing after all living

arrangement have been set up and the member is successfully in that living arrangement

and the SDCB budget, care plan and employees are approved to provide SDCB covered

services.

2. Voluntary Termination

SDCB members may transfer from the SDCB to the ABCB at any time. To the extent possible, the

SDCB member shall provide his/her SDCB provider(s) with 10 business days advance notice

regarding his/her intent to withdraw from the SDCB. All transfers will become effective on the 1

day of the following month.

3. Involuntary Termination

Reasons SDCB members may be involuntarily terminated from the SDCB and offered services

through the ABCB include, but are not limited to, the following circumstances:

A. The SDCB member refuses to follow SDCB rules after receiving: focused technical

assistance on multiple occasions; and support from the program staff, care

coordinator/support broker, or FMA that is supported with documentation of the efforts to

assist the SDCB member. Focused technical assistance is defined as a minimum of three

(3) separate occasions where the member /EOR have received training, education or

technical assistance, or a combination of both;

B. The SDCB member has immediate risk to his/her health or safety by continued self-

direction of services, e.g., the SDCB member is in imminent risk of death or serious bodily

injury related to participation in the SDCB. Examples include, but are not limited to, the

following:

a. The SDCB member refuses to include and maintain services in his/her SDCB care

plan that would address health and safety issues identified in the member’s in

his/her CNA medical assessment or challenges the assessment after repeated and

focused technical assistance and support from program staff, care

coordinator/support broker, PCS Agency, or FMA;

b. The SDCB member is experiencing significant health or safety needs, and, after

having been referred to the State contractor team (that includes the appropriate

State program manager and additional parties as deemed necessary by the State) for

technical assistance, refuses to incorporate the team’s recommendations into his/her

SDCB Care Plan, or the SDCB member exhibits behaviors which endanger him/her

or others;

c. The SDCB member misuses SDCB funds following repeated and focused technical

assistance and support from the care coordinator/support broker or FMA, which is

supported by documentation;

d. The SDCB member expends his/her entire SDCB budget prior to the end of the

SDCB care plan year; or

e. The SDCB member commits Medicaid fraud such as, for example, altering SDCB

employee/vendor payment checks.

C. The final decision to terminate a SDCB member and move him/her to ABCB is made by

the state. The MCO shall submit sufficient documentation to the state for approval of the

involuntary termination request. Upon state approval, the MCO shall notify the member

of the involuntary termination, in writing, and shall include appeal rights per HSD rules.

SDCB Involuntary Terminations may become effective any time during the month”.

D. Reinstatement to SDCB

Requests to be reinstated back to SDCB may be made one time during a 12-month period.

The member must make the request to his/her MCO in writing. All members shall be

required to participate in SDCB training prior to their reinstatement.

a. A SDCB member who voluntarily terminated his/her participation in SDCB may

request to move back from ABCB to SDCB any time during a 12-year month

period. The final decision to allow the reinstatement to SDCB is at the discretion

of the MCO. The care coordinator must ensure the transition does not cause a

break in services.

b. A SDCB member who was involuntarily terminated from SDCB may request to be

reinstated to SDCB once per 12-month period. The final decision to allow the

reinstatement to SDCB is at the discretion of the state. The MCO shall submit

sufficient documentation to the state for approval of reinstatement to the SDCB. If

approved, the care coordinator shall work with the FMA to ensure that the issues

previously identified as reasons for termination have been adequately addressed

prior to the reinstatement.

See the Appendices that also relate to SDCB:

 Appendix C: Range of Rates and Service Codes

 Appendix D: Vendor Credentialing Requirements Grid

 Appendix E: Employee Credentialing Requirements Grid

 Appendix F: Toolkit: Vendor

 Appendix G: Toolkit: Employee

 Appendix H: List of SDCB Acronyms

APPENDIX C: SDCB RANGE OF RATES CHART

SDCB SERVICE

BILLING

CODE

INTERNAL

FOCoS

CODE

UNIT

SDCB PAYMENT

RATE

Homemaker/Direct Support

99509

Hour

$7.50 (minimum wage)

- $14.60

Home Health Aide

S9122

Hour

$16.32

Employment Supports (includes Job Coach)

T2019

15 min.

$2.15 - $6.93

Job Developer (Per job that is developed for

member)

T2019

T2019JD

Each

$100-$700

Customized Community Supports (adult day hab.)

S5100

15 min.

$1.36-$8.82

Physical Therapy

G0151

15 min.

$13.51 - $24.22

Occupational Therapy

G0152

15 min.

$12.74 - $23.71

Speech/Language Pathology

G0153

15 min.

$16.06 - $24.22

Behavior Support Consultation

H2019

15 min.

$12.24 - $20.65

Private Duty Nursing – Adults- RN

T1002

15 min.

$10.90

Private Duty Nursing – Adults- LPN

T1003

15 min

$6.79

Nutritional Counseling

S9470

Hour

$42.83

Acupuncture

97810

15 min.

$12.50-$25.00

Biofeedback

90901

Visit

$50.00-$100.00

Chiropractic

98940

Visit

$50.00-$100.00

Cognitive Rehab Therapy

97532

15 min.

$12.50-$25.00

Hippotherapy

S8940

Visit

$50.00-$100.00

Massage Therapy

97124

15 min.

$12.50-$25.00

Naprapathy

S8990

Visit

$50.00-$100.00

Native American Healers

S9445

Session

As approved by MCO

Play Therapy

H2032

15 min

$12.50-$25.00

Respite Standard (not provided by RN, LPN or

HHA)

T1005

T1005SD

15 min.

$3.38

Respite RN

T1005

T1005RN

15 min.

$10.90

Respite LPN

T1005

T1005LPN

15 min.

$6.79

Respite Home Health Aide

T1005

T1005HHA

15 min.

$4.08

Emergency Response (monthly fee)

S5161

Each

$36.71-$40.79

Emergency Response (testing and maintenance)

S5160

Each

As approved by MCO

Environmental Modifications

S5165

Each

As approved by MCO

(maximum of $5,000

every 5 years)

Transportation Time

T2007

Hour

Minimum wage -$14.60

Transportation Trip

T2003

Each

As approved by MCO

Transportation Mile

T2049

Per

Mile

$0.34-$.40

Transportation Commercial Carrier Pass

T2004

Each

As approved by MCO

Fees and Memberships

T1999

T1999CP-I

Each

As approved by MCO

Coaching/education for parents, spouse or others

(not available for paid caregivers)

T1999

T1999CE-I

Each

As approved by MCO

Coaching/education for parents, spouse or others-

classes only (not available for paid caregivers)

T1999

T1999CL-I

Each

As approved by MCO

Coaching/education for parents, spouse or others-

conferences and seminars (not available for paid

caregivers)

T1999

T1999CS-I

Each

As approved by MCO

Technology for Safety and Independence

T1999

T1999TS

Each

As approved by MCO

Cell phone service (including data/GPS)

T1999

T1999CELL

Each

$0.00-$100.00

Cell phone and related equipment

T1999

T1999CPEP

Each

As approved by MCO

Cell phone/landline

T1999

T1999CPL

Each

As approved by MCO

Internet service

T1999

T1999IS

Each

As approved by MCO

Landline service

T1999

T1999LS

Each

As approved by MCO

Internet/cell phone

T1999

T1999IC

Each

As approved by MCO

Internet/cell phone/landline

T1999

T1999ICL

Each

As approved by MCO

Internet/landline

T1999

T1999IL

Each

As approved by MCO

Fax machine

T1999

T1999FX

Each

As approved by MCO

Computer

T1999

T1999CR

Each

As approved by MCO

Office supplies

T1999

T1999OS

Each

As approved by MCO

Printer

T1999

T1999PR

Each

As approved by MCO

Health-Related equipment and supplies

T1999

T1999HR-I

Each

As approved by MCO

Adaptive equipment and supplies

T1999

T1999AE-I

Each

As approved by MCO

Exercise equipment and related items

T1999

T199EE-I

Each

As approved by MCO

Nutritional supplements

T1999

T1999NS-I

Each

As approved by MCO

Over the counter medications

T1999

T1999OM-I

Each

As approved by MCO

Household related goods

T1999

T1999HG-I

Each

As approved by MCO

Appliances for independence

T1999

T1999AI-I

Each

As approved by MCO

Adaptive furniture

T1999

T1999AF-I

Each

As approved by MCO

APPENDIX D: SDCB VENDOR CREDENTIALING REQUIREMENTS

Requirements for enrolling Self-Directed Community Benefit (SDCB) Vendors

Before using any Vendor, please call Xerox (1-866-916-0310) to make sure all required vendor paperwork has been processed and that the vendor

has been set up on your SDCB Care Plan. If you use a vendor before their paperwork has been processed, they will not be paid for those dates.

All enrollment requirements (with the exception of the final criminal background check) must be processed before services can be provided.

Services that are provided prior to enrollment will not be paid by Medicaid or Xerox.

If a vendor provides only related goods (not services), you will only need to complete the Vendor Information Form (you do not need to

complete the entire Vendor Packet). We use the Vendor Information Form (VIF) to show that you will be using this vendor on your Plan. Since

vendors that provide related goods are usually large companies (for example: CenturyLink, Comcast, Wal-Mmart, K-Mart, Best Buy), it is not

necessary to get their signature on the form. If you are not sure if what you want to purchase is a “good” or a “service,” please call Xerox for

assistance.

Vendors (Independent Contractors and Agencies) that provide SERVICES

Ag = Agency, IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

97810

Acupuncture

Allowed Providers: Group Practice or Individual

Specialized Therapist

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: Acupuncture and/or oriental medicine

license

H2019

Behavior Support Consultation

Allowed Providers: Individual Behavior Support

Consultant (BSC) or BSC Group Practice

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: Licensed (MD, Clinical Psychologist,

Psychologist Associate, SW, LPCC, LPC,

Psychiatric Nurse, NM licensed marriage and

family therapist, NM licensed art therapist)

90901

Biofeedback

Allowed Providers: Group Practice or Individual

Specialized Therapist

Visit

Agency: Yes

IC: Yes

Agency: Business License

IC: License in Health Care Profession whose

scope of practice includes Biofeedback

98940

Chiropractic

Allowed Providers: Group Practice or Individual

Chiropractor

Visit

Agency: Yes

IC: Yes

Agency: Business License

IC: Chiropractic Physician License

T1999CE-I

Coaching Education for Parents, Spouse or Other

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

Agency: Business License

IC: Pre-Hire Packet

T1999CS-I

Coaching Education for Parents/Spouse: Conferences

and Seminars ONLY

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

Vendors (Independent Contractors and Agencies) that provide SERVICES *

IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

T1999CL-I

Coaching Education for Parents/Spouse: Classes ONLY

Allowed Providers: Vendor

Each

Agency:

IC: Yes

Yes

VIF is required (goods only)

97532

Cognitive Rehab Therapy

Allowed Providers: Group practice or Individual

Specialized Therapist

Per 15

min

Agency:

IC: Yes

Yes

Agency: Business License

IC: License in Health Care Profession whose

scope of practice includes Cognitive Rehab

Therapy

S5100

Customized Community Support

Allowed Providers: Adult Day Health Agency or Adult

Day Habilitation Agency

Per 15

min

Agency:

Yes

Agency: Business License

S5160

Emergency Response Testing and Maintenance

Allowed Providers: Emergency Response Provider

(Agency)

Each

Agency:

Yes

Agency: Business License

S5161

Emergency Response Monthly Service Fee

Allowed Providers: Emergency Response Provider

(Agency)

Monthly

Agency:

Yes

Agency: Business License

T2019

Employment Supports (includes Job Coach)

Allowed Providers: Supported Employment Provider

Agency or Individual

Each

Agency:

IC: Yes

Yes

Agency: Business License

IC: Pre-Hire Packet

S5165

Environmental Modifications (EMOD)

Allowed Providers: Individual or Company (Agency)

Each

Agency:

IC: Yes

Yes

Agency: Appropriate License

IC: Appropriate License

T1999CP-I

Fees and Memberships

Allowed Providers: Vendor

Each

Agency:

IC: Yes

Yes

VIF is required (goods only)

T1999HR-I

Health-Related Equipment & Supplies

Allowed Providers: Vendor

Each

Agency:

IC: Yes

Yes

VIF is required (goods only)

T1999AE-I

Adaptive Equipment and Supplies

Allowed Providers: Vendor

Each

Agency:

IC: Yes

Yes

VIF is required (goods only)

T1999EE-I

Exercise Equipment and Related Items

Allowed Providers: Vendor

Each

Agency:

IC: Yes

Yes

VIF is required (goods only)

T1999NS-I

Nutritional Supplements

Allowed Providers: Vendor

Each

Agency:

IC: Yes

Yes

VIF is required (goods only)

Vendors (Independent Contractors and Agencies) that provide SERVICES *

IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

T1999OM-I

Over-the-Counter Medications

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

S8940

Hippotherapy

Allowed Providers: Group Practice or Individual

Specialized Therapist

Visit

Agency: Yes

IC: Yes

Agency: Business License

IC: License in Healthcare profession whose

scope of practice includes hippotherapy.

S9122

Home Health Aide

Allowed Providers: Home Health Agency/Homemaker

Agency

Hour

Agency: Yes

Agency: Business License

99509

Homemaker/Direct Support

Allowed Providers: Individual Homemaker/Direct

Support Provider or Home Health Agency/Homemaker

Agency

Hourly

Agency: Yes

IC: Yes

Agency: Business License

IC: Pre-Hire Packet

T1999HG-H

Household Related Goods and Services Hourly

Allowed Providers: Vendor

Hourly

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999HG-I

Household Related Goods and Services Item/Invoice

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999AI-I

Appliances for Independence Item/Invoice

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999AF-I

Adaptive Furniture Item/Invoice

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T2019JD

Job Developer

Allowed Providers: Supported Employment Provider

Agency or Individual

Each

Agency: Yes

IC: Yes

Agency: Business License

IC: Pre-Hire Packet

Vendors (Independent Contractors and Agencies) that provide SERVICES *

IC = Independent Contractor

Service Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

97124

Massage Therapy

Allowed Providers: Group Practice or Individual

Specialized Therapist

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: Massage Therapist License

S8990

Naprapathy

Allowed Providers: Group Practice or Individual

Specialized Therapist

Visit

Agency: Yes

IC: Yes

Agency: Business License

IC: Naprapathic Physician License

S9445

Native American Healers

Allowed Providers: Group Practice or Individual

Specialized Therapist

Session

Agency: Yes

IC: Yes

IC: Pre-Hire Packet

S9470

Nutritional Counseling

Allowed Providers: Group Practice or Individual

Hourly

Agency: Yes

IC: Yes

Agency: Business License

IC: Registered Dietician License

G0152

Occupational Therapy

Allowed Providers: Individual Occupational Therapist

or Group Practice

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: OT License

G0151

Physical Therapy

Allowed Providers: Group Practice or Individual

Physical Therapist

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: PT License

H2032

Play Therapy

Allowed Providers: Group Practice or Individual

Specialized Therapist

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: Licensure in a mental health profession

whose scope of practice includes play therapy

T1003

Private Duty Nursing LPN

Allowed Providers: Home Health Agency, Rural Health

Clinic, FQHC or Individual

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: LPN License

T1002

Private Duty Nursing RN

Allowed Providers: Home Health Agency, Rural

Health Clinic, FQHC or Individual

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: RN License

T1005HHA

Respite Home Health Aide

Allowed Providers: Respite Agency

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

T1005SD

Respite Standard

Allowed Providers: Individual Provider (not RN, LPN

or HHA) or Respite Provider Agency

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: Pre-Hire Packet

Vendors (Independent Contractors and Agencies) that provide SERVICES *

IC = Independent Contractor

Service

Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

T1005LPN

Respite LPN

Allowed Providers: Respite Provider Agency or

Individual LPN

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: LPN License

T1005RN

Respite RN

Allowed Providers: Respite Provider Agency or

Individual RN

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: RN License

G0153

Speech/Language Pathology

Allowed Providers: Individual Speech Language

Pathologist (SLP) or Group Practice

Per 15

min

Agency: Yes

IC: Yes

Agency: Business License

IC: RN License

T1999TS

Technology for Safety and Independence

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999CR

Computer Purchase (item)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999PR

Printer Purchase (item)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999FX

Fax Machine Purchase (item)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999CPEP

Cell Phone and Related Equipment Purchase (item)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999IS

Internet Service

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999CELL

Cell Phone Service

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999LS

Landline Service

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999ICL

Internet/Cell Phone/Landline Service (bundled)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999IC

Internet/Cell Phone Service (bundled)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999IL

Internet/Landline Service (bundled)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

Vendors (Independent Contractors and Agencies) that provide SERVICES *

IC = Independent Contractor

Service

Code

Service Code Description

Billing

Method

Vendor Packet

License and/or Additional Requirements

T1999CPL

Cell Phone/Landline Service (bundled)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T1999OS

Office Supplies (purchased as items)

Allowed Providers: Vendor

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T2004

Transportation Commercial Carrier Pass

Allowed Providers: Transportation Commercial Carrier

Each

Agency: Yes

IC: Yes

VIF is required (goods only)

T2007

Transportation Time

Allowed Providers: Transportation Agency or Individual

Driver

Hourly

Agency: Yes

IC: Yes

Agency: Business License

IC: Transportation Appendix, Pre-Hire Packet

T2003

Transportation Trip

Allowed Providers: Transportation Agency or Individual

Driver

Each

Agency: Yes

IC: Yes

Agency: Business License

IC: Transportation Appendix, Pre-Hire Packet

T2049

Transportation Mile

Allowed Providers: Transportation Agency or Individual

Driver

Per Mile

Agency: Yes

IC: Yes

Agency: Business License

IC: Transportation Appendix, Pre-Hire Packet

If the vendor has a professional license (such as a registered nurse or therapist), their licensing board has already completed a

background check. They do not need to do another one for Mi Via. Provider agencies are responsible for completing criminal

background checks (CBC) on all their staff. Confirmation of the CBC must be available to the State and Xerox for review as

requested.

Please remember that at the beginning of each SDCB Care Plan year (annual renewal), new Vendor Agreements are required for any

vendor providing services. If ACS does not receive a Vendor Agreement before your new Plan starts, your vendor will not be set up

on your new Plan and they may be paid late. Please call Xerox (1-866-916-0310) before your new SDCB Care Plan starts so you can

make sure all your SDCB providers are set up for payment.

The above grid provides an overview of general vendor credentialing requirements. In certain specific cases, additional licensing or