MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC INDEX
INDEX
8.315.4 PERSONAL CARE OPTION SERVICES
8.315.4.1 ISSUING AGENCY.............................................................................................................1
8.315.4.2 SCOPE.................................................................................................................................1
8.315.4.3 STATUTORY AUTHORITY...............................................................................................1
8.315.4.4 DURATION.........................................................................................................................1
8.315.4.5 EFFECTIVE DATE..............................................................................................................1
8.315.4.6 OBJECTIVE .........................................................................................................................1
8.315.4.7 DEFINITIONS.....................................................................................................................1
8.315.4.8 MISSION STATEMENT .....................................................................................................1
8.315.4.9 PERSONAL CARE OPTION SERVICES...........................................................................1
8.315.4.10 CONSUMER-DIRECTED PERSONAL CARE ..................................................................2
8.315.4.11 CONSUMER-DELEGATED PERSONAL CARE ..............................................................5
8.315.4.12 ELIGIBLE POPULATION...................................................................................................10
8.315.4.13 COVERAGE CRITERIA .....................................................................................................10
8.315.4.14 COVERED SERVICES........................................................................................................10
8.315.4.15 NON-COVERED SERVICES..............................................................................................12
8.315.4.16 THIRD-PARTY ASSESSOR (TPA) ....................................................................................12
8.315.4.17 PRIOR APPROVAL AND UTILIZATION REVIEW.........................................................13
8.315.4.18 TRANSFER PROCESS........................................................................................................14
8.315.4.19 DISCHARGE PROCESS .....................................................................................................15
8.315.4.20 REIMBURSEMENT ............................................................................................................15
8.315.4.21 OTHER................................................................................................................................16
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PERSONAL CARE OPTION SERVICES
8.315.4 NMAC INDEX
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PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 1
TITLE 8 SOCIAL SERVICES
CHAPTER 315 OTHER LONG TERM CARE SERVICES
PART 4 PERSONAL CARE OPTION SERVICES
8.315.4.1 ISSUING AGENCY: New Mexico Human Services Department.
[8.315.4.1 NMAC - Rp 8 NMAC 4.MAD.000.1, 7/1/04]
8.315.4.2 SCOPE: The rule applies to the general public.
[8.315.4.2 NMAC - Rp 8 NMAC 4.MAD.000.2, 7/1/04]
8.315.4.3 STATUTORY AUTHORITY: The New Mexico medicaid program is administered
pursuant to
regulations promulgated by the federal department of health and human services
under Title XIX of the Social
Security Act, as amended and by the state human services department pursuant
to state statute. See Section 27-2-12
et seq. NMSA 1978 (Repl. Pamp. 1991).
[8.315.4.3 NMAC - Rp 8 NMAC 4.MAD.000.3, 7/1/04]
8.315.4.4 DURATION: Permanent
[8.315.4.4 NMAC - Rp 8 NMAC 4.MAD.000.4, 7/1/04]
8.315.4.5 EFFECTIVE DATE: July 1, 2004 unless a later date is cited at the
end of a section.
[8.315.4.5 NMAC - Rp 8 NMAC 4.MAD.000.5, 7/1/04]
8.315.4.6 OBJECTIVE: The objective of these regulations is to provide policies
for the service portion of
the New Mexico medicaid program. These policies describe eligible providers,
covered services, noncovered
services, utilization review, and provider reimbursement.
[8.315.4.6 NMAC - Rp 8 NMAC 4.MAD.000.6, 7/1/04]
8.315.4.7 DEFINITIONS: [RESERVED]
8.315.4.8 MISSION STATEMENT: The mission of the New Mexico medical assistance
division (MAD)
is to maximize the health status of medicaid-eligible individuals by furnishing
payment for quality health services at
levels comparable to private health plans.
[8.315.4.8 NMAC - Rp 8 NMAC 4.MAD.002, 7/1/04]
8.315.4.9 PERSONAL CARE OPTION SERVICES: Personal care option (PCO) is a
program for
qualified individuals 21 years of age or older who are eligible for full
medicaid coverage, and meet the nursing
facility (high or low NF) level of care criteria pursuant to Attachment
II of 8.312.2-UR, Long Term Care Services
Utilization Review Instructions for Nursing Facilities. These utilization
review instructions can be obtained from
the medical assistance division. It should be noted that personal care services
for individuals under the age of 21 are
reimbursed by the New Mexico medicaid program through the early periodic
screening, diagnostic and treatment
(EPSDT) services described in 8.323.2 NMAC, EPSDT Personal Care Services.
A. The goal of the PCO program is to avoid institutionalization, maintain
or increase the individualÆs
functional level and maintain or increase the individualÆs independence.
The PCO program does not provide
services 24 hours a day. PCO is a medicaid service, not a medicaid category,
and services under this option are
delivered pursuant to a personal care service plan (PCSP). PCO services
include a range of services to consumers
who are unable to perform some/all activities of daily living (ADLs) or
independent activities of daily living
(IADLs) because of a disability or a functional limitation(s). PCO services
permit an individual to live in his or her
home rather than an institution and allow him or her to maintain or increase
independence. These services include,
but are not limited to, bathing, dressing, grooming, eating, toileting,
shopping, transporting, caring for assistance
animals, cognitive assistance and communicating.
B. An individual may be physically capable of performing ADLs or IADLs but
may have limitations
in performing these activities because of a cognitive impairment. PCO services
may be required because a cognitive
impairment prevents an individual from knowing when or how to carry out
the task. In such cases, personal care
may include cueing along with supervision to ensure that the individual
performs the task properly.
C. Individuals eligible for PCO services will have the option of choosing
the consumer-directed
personal care model or the consumer-delegated personal care model. Under
both models, the consumer may select a
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 2
family member (except a spouse), friend, neighbor or other individual as
their attendant. The consumer-directed
model allows the consumer to act as the employer, oversee his/her own service
care delivery, and is required to work
with a fiscal intermediary agency to process all financial paperwork to
medicaid. Under the consumer-delegated
model, the consumer chooses the agency to perform all employer-related tasks
and the agency is responsible for
ensuring all service delivery to the consumer.
D. The third-party assessor or MADÆs designee is responsible for explaining
both models to each
individual initially and annually thereafter, assessing each individual
applying for PCO services, making a medical
level of care determination and allocating PCO services based on that individualÆs
needs. Medicaid-eligible
individuals or their personal representatives (as defined in 8.300.2.7 NMAC)
may contact their SALUD! managed
care organization (MCO) or MADÆs designated third-party assessor to
apply for personal care services.
[8.315.4.9 NMAC - Rp 8 NMAC 4.MAD.738, 7/1/04; A, 8/13/04]
8.315.4.10 CONSUMER-DIRECTED PERSONAL CARE: The consumer or the consumerÆs
personal
representative retains responsibility for performing employer-related tasks.
A. The consumerÆs or personal representativeÆs responsibilities
include:
(1) interviewing, hiring, training, terminating, and scheduling personal
care attendants. This includes,
but is not limited to:
(a) verifying that the attendant possesses a current/valid New Mexico driverÆs
license if there
are any driving-related activities listed on the personal care service plan
(PCSP); a copy of the driverÆs license must
be in the attendantÆs personnel file;
(b) verifying that the attendant has proof of current liability automobile
insurance if the
consumer is to be transported in the attendantÆs vehicle at any time;
(c) identifying training needs for the attendants.
(2) developing a list of attendants who can be contacted when an unforeseen
event occurs that
prevents the consumerÆs regularly scheduled attendant from providing
services;
(3) verifying that services have been rendered by completing, signing and
submitting documentation
the agency for payroll; a consumer or his/her personal representative is
responsible for ensuring the submission of
accurate timesheets; payment shall not be issued without appropriate documentation;
(4) notifying the agency, within one (1) working day, of the date of hire
and/or the date of
termination of his/her attendant;
(5) notifying and submitting a report of an incident to the agency, within
24 hours, so that the agency
can submit an incident report to MAD or its designee on behalf of the consumer;
the consumer or his/her personal
representative is responsible for completing the incident report;
(6) ensuring that the elected individual for hire has submitted to a request
for a nationwide criminal
history screening, pursuant to 7.1.9 NMAC and in accord with NMSA 1978,
Section 29-17-1 of the Caregivers
Criminal History Screening Act, within 30 days of the individual beginning
employment; the consumer must work
with the elected agency to complete all paperwork required for submitting
the nationwide criminal history screening;
the consumer may conditionally (temporarily) employ the individual contingent
upon the receipt of written notice of
the nationwide criminal history screening; a consumer may not continue employing
an attendant who does not
successfully pass a nationwide criminal history screening; and
(7) obtaining from the attendant a signed agreement, in which the attendant
agrees that he will not
provide PCO services while under the influence of drugs and/or alcohol and
acknowledges that if he is under the
influence of drugs and/or alcohol while providing PCO services he will be
immediately terminated; the consumer or
his personal representative shall not employ an attendant who has previously
been terminated from employment for
use of drugs and/or alcohol while providing PCO services;
(8) ensuring that if the consumerÆs legal guardian or attorney-in-fact
is the elected individual for hire,
prior approval has been obtained from MAD or its designee prior to employing
that individual; any PCO services
provided by the consumerÆs legal guardian or attorney-in-fact MUST
be justified, in writing, by the PCO agency and
consumer and submitted for approval to MAD or its designee prior to employment;
the justification must
demonstrate and prove the lack of other qualified attendants in the applicable
area; documentation of approval by
MAD or its designee must be maintained in the consumerÆs file; the
consumer is responsible for immediately
informing the agency if the consumer has appointed or elects a legal guardian
or attorney-in-fact any time during the
plan year.
B. The consumer-directed personal care agencyÆs responsibilities include:
(1) furnishing services to medicaid consumers that comply with all specified
medicaid participation
requirements outlined in 8.302.1 NMAC, General Provider Policies;
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PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 3
(2) verifying every month that all consumers are eligible for full medicaid
coverage prior to
furnishing services pursuant to Subsection A of 8.302.1.11 NMAC, General
Provider Policies; agencies must
document the date and method of eligibility verification; possession of
a medicaid card does not guarantee a
consumerÆs financial eligibility because the card itself does not
include financial eligibility, dates or other limitations
on the consumerÆs financial eligibility; agencies that provide PCO
services to consumers who are not financially
eligible cannot bill medicaid or the consumer for PCO services rendered
to the consumer;
(3) maintaining records that are sufficient to fully disclose the extent
and nature of the services
furnished to the consumers as outlined in 8.302.1 NMAC, General Provider
Policies;
(4) passing random and targeted audits, conducted by the department or its
audit agent, that ensure
agencies are billing appropriately for services rendered; the department
or its designee will seek recoupment of
funds from agencies when audits show inappropriate billing for services;
(5) providing either the consumer-directed or the consumer-delegated models,
or both models;
(6) furnishing their consumers, upon request, with information regarding
each model; if the consumer
chooses a model that an agency does not offer, the agency must refer the
consumer to an agency that offers that
model; the third-party assessor is responsible for explaining each model
in detail to consumers on an annual basis;
(7) maintaining appropriate record keeping of services provided and fiscal
accountability as required
by the MAD 335;
(8) ensuring that each consumer served has a current, approved PCSP on file;
(9) performing the necessary nationwide criminal history screening, pursuant
to 7.1.9 NMAC and in
accord with NMSA 1978, Section 29-17-1 of the Caregivers Criminal History
Screening Act, on all potential
personal care attendants; nationwide criminal history screenings must be
performed by an agency certified to
conduct such checks; the agency must work with the consumer to ensure the
paperwork is submitted within the first
30 days of hire; consumers under the consumer-directed model may conditionally
(temporarily) employ an attendant
until such check has been returned from the certified agency; if the attendant
does not successfully pass the
nationwide criminal history screening, the consumer may not continue to
employ the attendant;
(10) obtaining from the consumer or his personal representative a signed
agreement with the
attendant in which the attendant agrees that he will not provide PCO services
while under the influence of drugs
and/or alcohol and acknowledges that if he is under the influence of drugs
and/or alcohol while providing PCO
services he will be immediately terminated; the agency must maintain a copy
of the signed agreement in the
attendantÆs personnel file, for the consumer.
(11) obtaining a signed agreement from each consumer accepting responsibility
for all aspects of care
and training not included under the consumer-directed option; mandatory
training in CPR and first aid for all
attendants, competency testing, TB testing, hepatitis B immunizations and
supervisory visits are not included in the
consumer-directed option; a copy of the signed agreement must be maintained
in the consumerÆs file;
(12) verifying that if the consumer has elected the consumerÆs legal
guardian or attorney-in-fact as
his/her attendant, the agency and the consumer has obtained prior approval
from MAD or its designee; any personal
care services provided by the consumerÆs legal guardian or attorney-in-fact
MUST be justified, in writing, by the
agency and consumer and submitted for approval to MAD or its designee prior
to employment; the justification must
demonstrate and prove the lack of other qualified attendants in the applicable
area; documentation of approval by
MAD or its designee must be maintained in the consumerÆs file; the
agency must inform the consumer that if the
consumer is appointed or elects a legal guardian or attorney-in-fact any
time during the plan year, the consumer
must notify the agency immediately and the agency must ensure appropriate
documentation is maintained in the
consumerÆs file;
(13) producing reports as required by the department;
(14) verifying that consumers will not be receiving services through the
following programs while
they are receiving PCO services: a medicaid home and community-based waiver
(HCBW), medicaid nursing
facility (NF), intermediate care facility/mentally retarded (ICF/MR), PACE,
CYFD attendant care program, or
medicaid hospice; an individual residing in a NF or ICF/MR or receiving
community-based services is eligible to
apply for PCO services; all individuals must meet the financial/medical
eligibility requirements under the PCO
program to receive PCO services; the third-party assessor, MAD, or its designee
must conduct an assessment or
evaluation to determine if the transfer is appropriate and if the PCO program
would be able to meet the needs of that
individual;
(15) processing all claims for PCO services; payment shall not be issued
without appropriate
documentation;
(16) making a referral to an appropriate social service or legal agency(s)
for assistance, if the agency
questions whether the consumer is able to direct his/her own care.
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 4
(17) establishing and explaining to the consumer the necessary payroll documentation
needed for
reimbursement of PCO services, such as time sheets and tax forms;
(18) performing payroll activities for the attendants, such as, but not
limited to, income tax and social
security withholdings;
(19) informing the consumer and his/her attendant on the responsibilities
of the agency;
(20) arranging for state of New Mexico workersÆ compensation insurance
for all attendants;
(21) informing the consumer of available resources for necessary training,
if requested by the
consumer, in the following areas:
(a) hiring, recruiting, training, and supervision of attendants, including
advertising and
interviewing techniques; and
(b) evaluating methods of attendant competence and effectiveness.
(22) submitting written incident reports to MAD or its designee, on behalf
of the consumer, by fax,
within 24 hours of the incident being reported to the agency; the agency
must provide the consumer with an
appropriate form for completion; reportable incidents may include, but are
not limited to:
(a) abuse, neglect and exploitation:
(i) Abuse is defined as the willful infliction of injury, unreasonable confinement,
intimidation, or punishment with resulting physical harm, pain or mental
anguish to a consumer.
(ii) Neglect is defined as the failure to provide goods and services necessary
to avoid
physical harm, mental anguish, or mental illness to a consumer.
(iii) Exploitation is defined as the deliberate misplacement or wrongful,
temporary or
permanent use of a consumerÆs belongings or money without the voluntary
and informed consent of the consumer.
(b) death:
(i) Unexpected death is defined as any death of an individual caused by
an accident, or
an unknown or unanticipated cause.
(ii) Natural/expected death is defined as any death of an individual caused
by a long-term
illness, a diagnosed chronic medical condition, or other natural/expected
conditions resulting in death.
(c) other reportable incidents:
(i) Environmental hazard is defined as an unsafe condition that creates
an immediate
threat to life or health of a consumer.
(ii) Law enforcement intervention is defined as the arrest or detention
of a person by a
law enforcement agency, involvement of law enforcement in an incident or
event, or placement of a person in a
correctional facility.
(iii) Emergency services refers to admission to a hospital or psychiatric
facility or the
provision of emergency services that results in medical care that is not
anticipated for this consumer and that would
not routinely be provided by a primary care provider.
(23) obtaining from the consumer a signed contract with the attendant in
which the attendant
acknowledges that if he is under the influence of drugs and/or alcohol while
providing PCO service, it will be
grounds for immediate termination;
(24) maintaining a consumer file and an attendant personnel file for the
consumer.
C. Eligible consumer-directed agencies: Personal care agencies must be certified
by MAD or its
designee. (A detailed guideline for all of the requirements can be obtained
through MADÆs fiscal agent.) To be
certified by MAD or its designee, agencies must meet the following conditions
and submit a packet (contents 1-5
described below) for approval to MADÆs fiscal agent or its designee
containing the following:
(1) a completed medicaid provider participation application (MAD 335);
(2) copies of successfully passed nationwide caregivers criminal history
screenings on employees
who meet the definition of ôcaregiverö and ôcare providerö
pursuant to 7.1.9 NMAC and in accord with NMSA
1978, Section 29-17-1 of the Caregivers Criminal History Screening Act;
(3) a copy of a current/valid business license or evidence of non-profit
status; after certification, a
copy of the business license/evidence of non-profit status must be kept
current and submitted annually;
(4) proof of liability and workersÆ compensation insurance; after
certification, proof of liability and
workersÆ compensation insurance must be submitted annually;
(5) a copy of written policies and procedures that address:
(a) MADÆs personal care option provider policies;
(b) personnel policies; and
(c) office requirements.
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 5
(i) Agencies must establish and maintain an official office for the conduct
of business
with posted hours of operation and a published phone number. Branch offices
must be within a one hundred (100)
mile radius of the agencyÆs main officeÆs physical location.
In order to ensure the health and safety of consumer, the
main agency can service up to a one hundred (100) mile radius of the agencyÆs
physical location. The satellite office
can also service up to one hundred (100) mile radius of its actual physical
location.
(ii) Agencies offices must meet all Americans with Disabilities Act (ADA)
requirements.
(iii) If agencies have branch offices, the branch office must have a qualified
on-site
administrator to handle day-to-day operations who receives direction and
supervision from the main/central office.
(d) quality improvement program to ensure adequate and effective operation,
including
documentation of quarterly activity that address, but are not limited to:
(i) service delivery;
(ii) operational activities;
(iii) quality improvement action plan; and
(iv) documentation of activities.
(6) a copy of a current and valid home health license, issued by the department
of health, division of
health improvement, licensing and certification (pursuant to 7.28.2 NMAC)
may be submitted in lieu of
requirements (3) and (5) above. After certification, a copy of a current
and valid home health license must be
submitted annually along with proof of liability and workersÆ compensation
insurance;
(7) after the packet is received and reviewed by MAD or its designee, the
agency will be contacted to
complete the rest of the certification process. This will require the agency
to:
(a) attend a mandatory MAD or its designeeÆs provider training session
prior to the delivery of
PCO services; and
(b) possess a letter from MAD or its designee changing provider status from
ôpendingö to
ôactiveö.
(8) any professional authorized to complete the medical assessment form
(MAD 075) under the PCO
program cannot also become a personal care agency.
D. The consumer-directed personal care attendant responsibilities and requirements
include:
(1) being hired by the consumer;
(2) not being the spouse or minor child of the consumer pursuant to 42 CFR
Section 440.167 and
CMS state medicaid manual section 4480-D;
(3) providing the consumer with proof of and copies of current/valid New
Mexico driverÆs license
and motor vehicle insurance policy if the attendant will be transporting
the consumer;
(4) being 18 years of age or older;
(5) ensuring that if the attendant is the consumerÆs legal guardian
or attorney-in-fact and is the elected
individual for hire, prior approval has been obtained from MAD or its designee;
any PCO services provided by the
consumerÆs legal guardian or attorney-in-fact MUST be justified, in
writing, by the agency and consumer and
submitted for approval to MAD or its designee prior to employment; the justification
must demonstrate and prove
the lack of other qualified attendants in the applicable area; documentation
of approval by MAD or its designee must
be maintained in the consumerÆs file; and
(6) successfully passing a nationwide criminal history screening, pursuant
to 7.1.9 NMAC and in
accord with NMSA 1978, Section 29-17-1 of the Caregivers Criminal History
Screening Act, performed by an
agency certified to conduct such checks; attendants are required to submit
to a criminal history screening within the
first 30 days of hire; an attendant may be conditionally (temporarily) hired
by the consumer contingent upon the
receipt of written notice of the nationwide criminal history screening;
attendants who do not successfully pass a
nationwide criminal history screening are not eligible for continued employment
under the PCO program.
(7) Ensuring while employed as an attendant he will not be under the influence
of drugs and/or
alcohol while performing PCO services; the attendant must complete and sign
an agreement with the consumer or
the consumerÆs personal representative in which the attendant acknowledges
that if he is under the influence of
drugs and/or alcohol while providing PCO services he will be immediately
terminated; attendants who have been
terminated for use of drugs and/or alcohol while providing PCO services
are not eligible for further employment
under the PCO program.
[8.315.4.10 NMAC - Rp 8 NMAC 4.MAD.738.1, 7/1/04; A, 8/13/04]
8.315.4.11 CONSUMER-DELEGATED PERSONAL CARE: The agency contracts with the
department
to perform employer-related tasks.
A. The consumer-delegated agency responsibilities include, but are not limited
to the following:
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 6
(1) employing, terminating and scheduling qualified attendants;
(2) training all attendants for a minimum of twelve (12) hours per year;
initial training must be
completed within the first three (3) months of employment and must encompass:
(a) an overview of the PCO program;
(b) living with a disability in the community;
(c) cardiopulmonary resuscitation (CPR) and first aid training; and
(d) a written competency test with a minimum passing score of seventy-five
(75%) or better;
expenses for all trainings are to be incurred by the agency; other trainings
may take place throughout the year as
determined by the agency; the agency must maintain in the attendantÆs
file copies of all trainings, certifications, and
specialty training the attendant completed. CPR and first aid certifications
must be kept current;
(i) documentation of all training must include at least the following information:
1)
name of individual taking training; 2) title, purpose, and objectives of
class; 3) name of instructor; 4) number of
hours of instruction; 5) date instruction was given;
(ii) documentation of competency testing must include at least the following:
1) name of
individual being evaluated for competency; 2) date and method used to determine
competency; 3) copy of the
attendantÆs competency test in the attendantÆs personnel file.
(3) submitting to the department of health (DOH) for inclusion on the PCO
attendant registry names
of all qualified PCO attendants who have completed the required training
and competency testing per subparagraphs
(a) through (d) of Paragraph (2) of Subsection A of 8.315.4 NMAC; the agency
must verify with DOH that PCO
attendants previously employed by other PCO agencies are in good standing
with DOH on the PCO attendant
registry and cannot employ attendants who are not in good standing;
(4) developing and maintaining a registry of trained and qualified attendants
as backup for regularly
scheduled attendants and emergency situations; complete instructions regarding
the consumerÆs care and a list of
attendant duties and responsibilities must be available in each consumerÆs
home;
(5) informing the attendant of the risks of hepatitis B infection and offering
hepatitis B immunization
at the time of employment at no cost to the attendant; attendants are not
considered to be at risk for hepatitis B since
only non-medical services are performed; therefore, attendants may refuse
the vaccine; documentation of the
immunization, prior immunization, or refusal of immunization by the attendant
must be in the attendantÆs personnel
file;
(6) providing the attendant with information on community resources and
information about the
specific populations being served;
(7) obtaining a copy of the attendantÆs current/valid New Mexico driverÆs
license and a copy of the
motor vehicle insurance policy if the consumer is to be transported by the
attendant; copies of the driverÆs license
and motor vehicle insurance policy must be maintained in the attendantÆs
personnel file;
(8) complying with federal and state regulations and labor laws.;
(9) preparing all documentation necessary for payroll; and
(10) producing reports as required by the department.
(11) complying with all specified medicaid participation requirements outlined
in 8.302.1 NMAC,
General Provider Policies;
(12) verifying every month that all consumers are eligible for full medicaid
coverage prior to
furnishing services pursuant to Subsection A of 8.302.1.11 NMAC, General
Provider Policies; agencies must
document the date and method of eligibility verification; possession of
a medicaid card does not guarantee a
consumerÆs financial eligibility because the card itself does not
include financial eligibility, dates or other limitations
on the consumerÆs financial eligibility; agencies that provide PCO
services to consumers who are not financially
eligible cannot bill medicaid or the consumer for PCO services rendered
to the consumer;
(13) maintaining records that are sufficient to fully disclose the extent
and nature of the services
furnished to the consumers as outlined in 8.302.1 NMAC, General Provider
Policies;
(14) passing random and targeted audits, conducted by the department or
its audit agent, that ensure
agencies are billing appropriately for services rendered; dhe department
or its designee will seek recoupment of
funds from agencies when audits show inappropriate billing for services;
(15) providing either the consumer-directed or the consumer-delegated models,
or both models;
(16) furnishing their consumers, upon request, with information regarding
each model; if the
consumer chooses a model that an agency does not offer, the agency must
refer the consumer to an agency that
offers that model; the third-party assessor is responsible for explaining
each model in detail to consumers on an
annual basis;
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 7
(17) maintaining appropriate record keeping of services provided and fiscal
accountability as required
by the MAD 335;
(18) ensuring that each consumer served has a current, approved PCSP on
file;
(19) performing the necessary nationwide criminal history screening, pursuant
to 7.1.9 NMAC and in
accord with NMSA 1978, Section 29-17-1 of the Caregivers Criminal History
Screening Act; the agency must
ensure that the individual has submitted to a request for a nationwide criminal
history screening within 30 days of
the individual beginning employment; nationwide criminal history screening
must be performed by an agency
certified to conduct such checks; agencies under the consumer-delegated
model may conditionally (temporarily)
employ an attendant until the nationwide criminal history screening has
been returned from the certified agency; if
the attendant does not successfully pass a nationwide criminal history screening,
the agency may not continue
employment;
(20) obtaining from the attendant a signed agreement, in which the attendant
agrees that he will not
provide PCO services while under the influence of drugs and/or alcohol and
acknowledges that if he is under the
influence of drugs and/or alcohol while providing PCO services he will be
immediately terminated; the agency shall
not employ an attendant who has previously been terminated from employment
for use of drugs and/or alcohol while
providing PCO services;
(21) ensuring that if the consumer has elected the consumerÆs legal
guardian or attorney-in-fact as
his/her attendant, the agency has obtained prior approval from MAD or its
designee; any PCO services provided by
the consumerÆs legal guardian or attorney-in-fact MUST be justified,
in writing, by the agency and consumer and
submitted for approval to MAD or its designee prior to employment; the justification
must demonstrate and prove
the lack of other qualified attendants in the applicable area; documentation
of approval by MAD or its designee must
be maintained in the consumerÆs file; the agency must inform the consumer
that if the consumer is appointed or
elects a legal guardian or attorney-in-fact any time during the plan year,
they must notify the agency immediately;
(22) producing reports as required by the department;
(23) verifying that consumers will not be receiving services through the
following programs, while
they are receiving PCO services: a medicaid home and community-based waiver
(HCBW), medicaid nursing
facility (NF), intermediate care facility/mentally retarded (ICF/MR), PACE,
CYFD attendant care program, or
medicaid hospice; an individual residing in a NF or ICF/MR or receiving
community-based services is eligible to
apply for PCO services; all individuals must meet the financial/medical
eligibility requirements under the PCO
program to receive PCO services; the third-party assessor, MAD, or its designee
must conduct an assessment or
evaluation to determine if the transfer is appropriate and if the PCO program
would be able to meet the needs of that
individual;
(24) processing all claims for PCO services; payment shall not be issued
without appropriate
documentation;
(25) making a referral to an appropriate social service or legal agency(s)
for assistance, if the agency
questions whether the consumer is able to direct his/her own care;
(26) establishing and explaining to all their consumers and all attendants
the necessary payroll
documentation needed for reimbursement of PCO services, such as time sheets
and tax forms;
(27) performing payroll activities for the attendants, such as, but not
limited to income tax and social
security withholdings;
(28) informing the consumer and his/her attendant on the responsibilities
of the agency;
(29) providing state of New Mexico workersÆ compensation insurance
for all attendants;
(30) submitting written incident reports to MAD or its designee, by fax,
within 24 hours of the
incident being reported to the agency; reportable incidents may include,
but are not limited to:
(a) abuse, neglect and exploitation:
(i) Abuse is defined as the willful infliction of injury, unreasonable confinement,
intimidation, or punishment with resulting physical harm, pain or mental
anguish to a consumer.
(ii) Neglect is defined as the failure to provide goods and services necessary
to avoid
physical harm, mental anguish, or mental illness to a consumer.
(iii) Exploitation is defined as the deliberate misplacement or wrongful,
temporary or
permanent use of a consumerÆs belongings or money without voluntary
and informed consent of the consumer.
(b) death:
(i) Unexpected death is defined as any death of an individual caused by
an accident, or
an unknown or unanticipated cause.
(ii) Natural/expected death is defined as any death of an individual caused
by a long-term
illness, a diagnosed chronic medical condition, or other natural/expected
conditions resulting in death.
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PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 8
(c) other reportable incidents:
(i) Environmental hazard is defined as an unsafe condition that creates
an immediate
threat to life or health of a consumer.
(ii) Law enforcement intervention is defined as the arrest or detention
of a person by a
law enforcement agency, involvement of law enforcement in an incident or
event, or placement of a person in a
correctional facility.
(iii) Emergency services refers to admission to a hospital or psychiatric
facility or the
provision of emergency services that results in medical care that is not
anticipated for this consumer and that would
not routinely be provided by a primary care provider.
(31) conducting supervisory visits in the consumerÆs home, once a
month at a minimum, which must
include a face-to-face interview with the consumer, and/or his/her personal
representative;
(32) documenting in the consumerÆs file the safety of the service
and the quality of care provided to
the consumer;
(33) arranging regular staff meetings and in-service training programs for
attendants; agencies must
bear expenses for all trainings but is not required to pay attendants for
his/her training time; attendants must receive
a minimum of 12 hours training per year, which must include CPR and first
aid and should be in-conjunction with
the consumers needs; agencies must ensure CPR and first aid trainings are
completed within the first three (3)
months of employment; agencies must annually resubmit to DOH the names of
all qualified PCO attendants upon
completion of their annual in-service requirements; agencies must ensure
that mandatory trainings are kept current
and that copies of all trainings and certifications are in the attendantÆs
personnel file;
(34) maintaining an accessible and responsive 24-hour communication system
for consumers to use
in emergency situations to contact the agency;
(35) maintaining a roster of trained and qualified attendants for backup
of regular scheduling and
emergencies;
(36) offering hepatitis B immunization at the time of employment at no cost
to the attendant and
inform the attendant of the risks of hepatitis B infection; the attendant
may refuse hepatitis B vaccination;
documentation of current immunization, prior immunization, or refusal of
immunization must be maintained in the
attendantÆs personnel file;
(37) obtaining a current tuberculosis (TB) skin test or chest x-ray upon
initial employment; TB
testing must be conducted thereafter, pursuant to the current standards
of the department of health; the results of the
TB skin test or chest x-ray must be documented in the attendantÆs
personnel file; if the individual tests positive for
TB, he/she cannot be hired as an attendant; the individual must be referred
to his/her physician or to the department
of health for infectious disease treatment; when the individual has received
appropriate treatment, he/she may be
employed as the attendant; there must be documentation of treatment from
a medical professional in the attendantÆs
personnel file; the agency must incur expenses for TB tests; and
(38) conducting or arranging for a written competency test (approved by
MAD or its designee as
stated in Paragraph (6) of Subsection B of 8.315.4.11 NMAC of these regulations),
at the agencyÆs expense, for all
eligible attendants; the attendant must successfully pass a written test
with seventy-five percent (75%) or better
within the first three (3) months of employment; a copy of the test must
be in the attendantÆs personnel file; special
accommodations must be made for attendants who are not able to read or write
or who speak/read/write a language
other than English;
B. Eligible consumer-delegated agencies: Personal care agencies must be
certified by the MAD or
its designee. (A detailed guideline to all of the requirements can be obtained
through MADÆs fiscal agent.) To be
certified by MAD or its designee, agencies must meet the following conditions
and submit a packet (contents 1-5
described below) for approval to MADÆs fiscal agent or its designee
containing the following:
(1) a completed medicaid provider participation application (MAD 335);
(2) copies of successfully passed caregivers criminal history screenings
on employees who meet the
definition of ôcaregiverö and ôcare providerö pursuant
to 7.1.9 NMAC and in accord with the Caregivers Criminal
History Screening Act;
(3) a copy of a current/valid business license or evidence of non-profit
status; after certification, a
copy of the business license/evidence of non-profit status must be kept
current and submitted annually;
(4) proof of liability and workersÆ compensation insurance; after
certification, proof of liability and
workersÆ compensation insurance must be submitted annually;
(5) a copy of written policies and procedures that address:
(a) MADÆs personal care option provider policies;
(b) personnel policies; and
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 9
(c) office requirements.
(i) Agencies must establish and maintain an official office for the conduct
of business
with posted hours of operation. Branch offices must be within a one hundred
(100) mile radius of the agencyÆs main
officeÆs physical location. In order to ensure the health and safety
of consumer, the main agency can service up to a
one hundred (100) mile radius of the agencyÆs physical location. The
satellite office can also service up to one
hundred (100) mile radius of its actual physical location.
(ii) Agencies must meet all Americans with Disabilities Act (ADA) requirements.
(iii) If agencies have branch offices, the branch office must have a qualified
on-site
administrator to handle day-to-day operations who receives direction and
supervision from the main/central office.
(d) quality improvement program to ensure adequate and effective operation,
including
documentation of quarterly activity that address, but are not limited to:
(i) service delivery;
(ii) operational activities;
(iii) quality improvement action plan;
(iv) documentation of activities.
(6) a copy of the agencyÆs written competency test for approval to
MAD or its designee; an agency
may elect to purchase a competency test or it may develop its own test;
the test must address at least the following:
(a) communication skills;
(b) patient/client rights, including respect for cultural diversity;
(c) recording or information for patient/client records;
(d) nutrition and meal preparation;
(e) housekeeping skills;
(f) care of the ill and disabled, including the special needs populations;
(g) emergency response (including CPR and first aid);
(h) basic infection control;
(i) home safety;
(7) a copy of a current and valid home health license, issued by the department
of health, division of
health improvement, licensing and certification (pursuant to 7.NMAC 28.2)
may be submitted in lieu of
requirements 3, 5 and 6 of this section; after certification, a copy of
a current and valid home health license must be
submitted annually along with proof of liability and workersÆ compensation
insurance;
(8) after MAD or its designee has received and reviewed the packet, the
agency will be contacted to
complete the rest of the certification process; this will require the agency
to:
(a) attend a mandatory MAD or its designeeÆs provider training session
prior to the delivery of
PCO services; and
(b) possess a letter from MAD or its designee changing provider status from
ôpendingö to
ôactiveö.
(9) any professional authorized to complete the medical assessment form
(MAD 075) under the PCO
program cannot also become a personal care agency.
C. The consumer-delegated personal care attendant responsibilities and requirements
include:
(1) being hired by the agency;
(2) not being the spouse or minor child of the consumer pursuant to 42 CFR
Section 440.167 and
CMS state medicaid manual section 4480-D;
(3) providing the agency with proof of and copies of current/valid New Mexico
driverÆs license and
motor vehicle insurance policy if the attendant will be transporting the
consumer;
(4) being 18 years of age or older;
(5) ensuring that if the attendant is the consumerÆs legal guardian
or attorney-in-fact and is the elected
individual for hire, prior approval has been obtained from MAD or its designee;
any personal care services provided
by the consumerÆs legal guardian or attorney-in-fact MUST be justified,
in writing, by the PCO agency and
consumer and submitted for approval to MAD or its designee prior to employment;
the justification must
demonstrate and prove the lack of other qualified attendants in the applicable
area; documentation of approval by
MAD or its designee must be maintained in the consumerÆs file;
(6) successfully passing a nationwide criminal history screening, pursuant
to 7.1.9 NMAC and in
accord with NMSA 1978, Section 29-17-1 of the Caregivers Criminal History
Screening Act, performed by an
agency certified to conduct such checks; attendants are required to submit
to a criminal history screening within the
first 30 days of hire; an attendant may be conditionally (temporarily) hired
by the consumer contingent upon the
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 10
receipt of written notice of the nationwide criminal history screening;
attendants who do not successfully pass a
nationwide criminal history screening are not eligible for employment under
the PCO program;
(7) ensuring while employed as an attendant he will not be under the influence
of drugs and/or
alcohol while performing PCO services; the attendant must complete and sign
an agreement with the agency in
which the attendant acknowledges that if he is under the influence of drugs
and/or alcohol while providing PCO
services he will be immediately terminated; attendants who have been terminated
for use of drugs and/or alcohol
while providing PCO services are not eligible for further employment under
the PCO program;
(8) successfully passing a written personal care attendant competency test
with seventy-five percent
(75%) or better within the first three (3) months of employment;
(9) completing 12 hours of training yearly; the attendant must obtain certification
of CPR and first aid
training within the first (3) three months of employment, and the attendant
must maintain certification throughout
the entire duration of providing PCO services; additional training will
be based on the consumerÆs needs as listed in
the PCSP; attendants are not required to be reimbursed for training time;
(10) being placed on DOHÆs PCO attendant registry and remaining in
good standing with DOH on
the PCO attendant registry; and
(11) providing the agency with a current tuberculosis (TB) skin test or
chest x-ray upon initial
employment with the agency per the current standards of the department of
health; the results of the TB test must be
documented in the attendantÆs personnel file; if the results are positive
for TB, the individual cannot be hired as an
attendant, and must seek treatment; after treatment and the individual has
been given medical clearance, the
individual may be employed by the agency; there must be documentation from
a medical professional of treatment,
and the agency must place a copy of the treatment documentation in the attendantÆs
personnel file.
[8.315.4.11 NMAC - Rp 8 NMAC 4.MAD.738.2, 7/1/04; A, 8/13/04]
8.315.4.12 ELIGIBLE POPULATION: Consumers receiving personal care services
must meet all of the
following criteria:
A. be on a full benefit medicaid category and not be receiving medicaid
home and community-based
waiver services (HCBS), medicaid nursing facility (NF), intermediate care
facility/mentally retarded (ICF/MR),
PACE, CYFD attendant care program, or medicaid hospice services at the time
PCO services are furnished; an
individual residing in a NF or ICF/MR or receiving community-based services
is eligible to apply for PCO services;
all individuals must meet the financial/medical eligibility requirements
under the PCO program to receive PCO
services; the third-party assessor, MAD, or its designee must conduct an
assessment or evaluation to determine if the
transfer is appropriate and if the PCO program would be able to meet the
needs of that individual;
B. be age twenty one (21) or older; be determined to have meet the level
of care required in a nursing
facility (high or low NF) by the third-party assessor or MADÆs designee;
C. have an approved PCSP, developed by the consumer or personal representative,
in conjunction
with the third-party assessor or MADÆs designee; and
D. comply with all medicaid policies and procedures.
[8.315.4.12 NMAC - Rp 8 NMAC 4.MAD.738.3, 7/1/04]
8.315.4.13 COVERAGE CRITERIA: Services under the personal care option program
are defined as those
tasks necessary a consumerÆs physical, social or cognitive functional
ability. The goal of personal care is to avoid
institutionalization, maintain or increase the consumerÆs functional
level, and maintain or increase the consumerÆs
independence. The personal care option program does not provide services
24 hours per day. Services are covered
under the following criteria:
A. PCO services are usually furnished in the consumerÆs place of residence.
Services may be
furnished outside the home, when appropriate and necessary and when not
available through other existing benefits
and programs, such as hospice and home health.
B. PCO services are not furnished to an individual who is an inpatient or
resident of a hospital,
nursing facility, intermediate care facility for the mentally retarded,
mental health facility, correctional facility, or
other institutional settings.
[8.315.4.13 NMAC - Rp 8 NMAC 4.MAD.738.7, 7/1/04]
8.315.4.14 COVERED SERVICES: Services covered under the PCO program are
the following:
A. Individualized bowel and bladder services: include but are not limited
to: diaper changes,
catheter care, bowel programs, bladder programs, and perineal care. These
services do not have to be performed by
a nurse pursuant to NMSA 1978, Section 61-3-29(J) of the Nursing Practice
Act. Bowel and bladder services may
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 11
be ôperformed by a personal care provider in a non-institutional setting
of bowel and bladder assistance for an
individual whom a health care provider certifies is stable, not currently
in need of medical care and able to
communicate and assess his own needs.ö
B. Meal preparation and assistance: at the direction of the consumer or
his/her personal
representative, prepare meal(s) for the consumer or assist the consumer
pursuant to the PCSP. This does not include
assistance with eating. Services requiring assistance with eating are covered
under eating in Subsection G of
8.315.4.14 NMAC below.
C. Support services: Provide additional assistance to the consumer in order
to promote his/her
independence and enhance his/her ability to live in the community and remain
in a clean and safe environment.
These services include, but are not limited to:
(1) shopping and/or completing errands for the consumer, with or without
the consumer;
(2) transporting and assisting with transfers in/out of vehicles; if the
consumerÆs vehicle is used, the
consumer must have a copy of his/her motor vehicle insurance policy; agencies
are not required to provide escort or
transportation services; if the consumer requires transportation and the
agency cannot meet this need, the agency
must refer the consumer to personal care agencies that can meet this need;
the third-party assessor or MADÆs
designee will assess the consumerÆs formal and informal support systems
and determine the availability of other
transportation and/or other agencies such as a medicaid enrolled transportation
provider for transportation to medical
services; the third-party assessor or MADÆs designee will approve
transportation services primarily for non-medical
transportation, unless the consumer resides in a rural area and does not
have access to a medicaid-enrolled
transportation provider for medical-related transports;
(3) translating/interpreting through persons qualified to provide such services.
D. Hygiene/grooming: The PCSP may include the following tasks to be performed
by the attendant.
These services include but are not limited to:
(1) bathing;
(2) dressing;
(3) grooming;
(4) oral care with intact swallowing reflex;
(5) nail care;
(6) perineal care;
(7) toileting;
E. Minor maintenance of assistive device(s): Battery replacement and minor,
routine wheelchair
and durable medical equipment (DME) maintenance.
F. Mobility assistance: Assistance may include, but is not limited to:
(1) ambulation;
(2) transferring;
(3) toileting;
G. Eating: The attendant shall assist the consumer as determined by the
PCSP. This does not
include preparation of food/meals. Services requiring preparation of food/meals
is covered under meal preparation
and assistance in Subsection B of 8.315.4.14 NMAC. If the consumer has special
needs in this area, the attendant is
required to receive specific training to meet that need.
H. Assisting with self-administered medication: This service is limited
to prompting and
reminding only. A consumer who needs assistance with taking self-administered
medication as a reasonable
accommodation under the Americans with Disabilities Act (ADA) due to a disability
may receive assistance as per
the PCSP. Examples of assistance include, but are not limited to, the following:
(1) getting a glass of water or juice as requested by the consumer;
(2) handing the consumer his/her daily medication box or medication bottle,
or cutting/grinding pills;
(3) helping a consumer with placement of oxygen tubes.
I. Skin care: The consumer must have a documented skin disorder. If documented
by a physician,
physician assistant, nurse practitioner or clinical nurse specialist, the
attendant can perform skin care. Such
assistance excludes wound care or application of prescription medications
unless such assistance would be a
reasonable accommodation under the ADA.
J. Cognitive assistance: Cognitive assistance is intended to keep the consumer
on task, and increase
or maintain the consumerÆs safety, independence, and quality of life.
This service is primarily for a consumer with a
traumatic brain injury, alzheimerÆs disease, a mental illness, dementia,
or a consumer who has suffered a stroke;
K. Household services: The attendant will assist the consumer in performing
household activities as
needed. Such activities are limited to the maintenance of the consumerÆs
personal living area (i.e., kitchen, living
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 12
room, bedroom, and bathroom). These activities are considered necessary
to maintain a clean and safe environment
and to support the consumer living in his/her home. Examples of household
services include:
(1) sweeping, mopping or vacuuming the consumerÆs carpets, hardwood
floors, or linoleum;
(2) dusting the consumerÆs furniture;
(3) changing the consumerÆs linens;
(4) washing the consumerÆs laundry;
(5) cleaning the consumerÆs bathroom (tub and/or shower area, sink,
and toilet);
(6) cleaning the consumerÆs kitchen and dining area (i.e., washing
the consumerÆs dishes, putting the
consumerÆs dishes away; cleaning counter tops, cleaning the area where
the consumer eats, etc.).
[8.315.4.14 NMAC - Rp 8 NMAC 4.MAD.738.8, 7/1/04]
8.315.4.15 NON-COVERED SERVICES: The following services are not covered
under the New Mexico
medicaid personal care program:
A. any task that must be provided by a person with professional or technical
training as specified by
state and federal law;
B. services not approved in the consumerÆs approved PCSP; and
C. childcare or personal care for other household members.
[8.315.4.15 NMAC - Rp 8 NMAC 4.MAD.738.9, 7/1/04]
8.315.4.16 THIRD-PARTY ASSESSOR (TPA): The TPA or MADÆs designee is
responsible for making
level of care (LOC) determinations based on criteria developed by MAD or
its designee Attachment II of 8.312.2-
UR, Long Term Care Services Utilization Review Instructions for Nursing
Facilities, available upon request from
MAD; developing personal care service plans (PCSP), issuing prior approvals,
and making utilization reviews for all
PCO consumers. The TPA or MADÆs designee will explain, in detail,
the two service delivery models, consumerdirected
and consumer-delegated, annually; and is also required to provide the consumer
with informational
materials that explain both models and the PCO program in general. The TPA
is not authorized to contract with any
medicaid approved PCO agency to carry out TPA responsibilities. The TPAÆs
responsibilities are as described
below.
A. Level of care (LOC): To be eligible for PCO services, a consumer must
meet the level of care
required in a nursing facility, the medical eligibility criteria entails
two distinct levels of care: a high nursing facility
(HNF) or low nursing facility (LNF), Attachment II of 8.312.2-UR, Long Term
Care Services Utilization Review
Instructions for Nursing Facilities. A level of care packet is developed
and approved by the TPA or MADÆs
designee.
(1) The packet must include:
(a) a current (within the last 12 months) MAD 075 signed by a physician,
physician assistant,
nurse practitioner or, clinical nurse specialist;
(b) any other information or medical justification documenting the consumerÆs
functions
abilities.
(2) The TPA or MADÆs designee will use the LOC packet to:
(a) make all LOC determinations for all consumers requesting services under
the personal care
option program;
(b) approve the consumers LOC for a minimum of one year (12 consecutive
months); and
(c) contact consumer within a minimum of ninety (90) days, prior to the
expiration of the
approved LOC, to being LOC determination process for PCO services, to ensure
the consumer does not experience a
break in PCO services.
(3) An agency that does not agree with the LOC determination made by the
third-party assessor or
MADÆs designee may:
(a) request a re-review and/or reconsideration pursuant to medicaid oversight
policies, 8.350.2
NMAC, Reconsideration of Utilization Review Decisions [MAD-953]; and
(b) is responsible for submitting the additional medical justification to
the TPA or MADÆs
designee and adhering to the timelines as out lined in medicaid Oversight
Policies, 8.350.2 NMAC, Reconsideration
of Utilization Review Decisions [MAD-953].
(4) A consumer that does not agree with the LOC determination made by the
TPA or MADÆs
designee may request a fair hearing pursuant to 8.352.2 NMAC, Recipient
Hearings.
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 13
(5) Agencies that have identified a consumer with a declining health condition
or whose needs have
changed and believe the consumer is in need of more services should refer
the consumer to the TPA or MADÆs
designee for an additional assessment.
(6) Agencies who are providing PCO services to a consumer who becomes eligible
for and would
like to be placed onto the HCBS must submit a new LOC packet to MADÆs
utilization review contractor (UR) as
outlined in UR policy for HCBS waivers.
B. Personal care service plan (PCSP): The PCSP (MAD 058) is developed and
personal care
services are allocated, in conjunction with the in-home assessment (MAD
057, The Personal Care Option
Assessment Form) and the current medical assessment form (MAD 075) for all
consumers requesting services or
continued services under the PCO program.
(1) The TPA or MADÆs designee will:
(a) conduct an in-home assessment (MAD 057) in the consumerÆs home;
(b) explain both service delivery models, consumer-directed and consumer-delegated
to the
consumer and/or his/her personal representative and provide the consumer
and/or his/her personal representative
with informational material, allowing the consumer to make the best educated
decision possible regarding which
model he/she will elect;
(c) determine and allocate personal care services using the LOC packet and
the in-home
assessment (MAD 057) for the duration of one year (12 consecutive months);
(d) develop a PCSP in-conjunction with the consumer or his/her personal
representative;
participation in the development of a PCSP is not separately reimbursable
for consumers or his/her personal
representatives; the TPA or MADÆs designee must ensure the consumer
has participated in the development of the
plan and that the PCSP is reviewed and signed by the consumer and/or the
consumerÆs personal representative; a
signature on the PCSP indicates that the consumer an/or personal representative
agrees with the allocation of hours
made by the TPA or MADÆs designee and understands what services will
be provided on a weekly basis and for the
duration of one year; if a consumer is unable to sign the PCSP and the consumer
does not have a personal
representative, a thumbprint or personal mark (i.e., an ôXö)
will suffice; if signed by a personal representative, the
TPA or MADÆs designee and the agency must have documentation in the
consumerÆs file verifying the individual is
the consumerÆs personal representative; the PCSP must include the
following:
(i) description of the functional level of the consumer as evidenced by
the primary care
physicianÆs clinical evaluation, including mental status, intellectual
functioning and other supporting documentation;
(ii) statement of the nature of the specific limitations and the specific
needs of the
consumer for personal care services;
(iii) a specific description of the attendantÆs responsibilities,
including tasks to be
performed by the attendant and any special instructions related to maintaining
the health and safety of the consumer;
(iv) a description of intermediate and long range service goals, which includes
the scope
and duration of services, how goals will be attained and the projected timetable
for their attainment.
(v) a statement describing the most integrated setting necessary to achieve
the goals
identified in the plan; and
(vi) a prior authorization (PA) number issued to the agency of the consumerÆs
choice, for
on-going billing purposes; a HCPC code must be tied to the PA based on the
consumerÆs elected model of service
delivery.
(e) approve PCO services for the duration of one year (12 consecutive months);
(f) provide the consumer with a copy of their approved PCSP; and
(g) contact consumer within a minimum of ninety (90) days, prior to the
expiration of the
approved PCSP, to being the re-assessment process for PCO services, to ensure
the consumer does not experience a
break in PCO services.
(2) Personal care agencies must:
(a) obtain an approved PCSP (MAD 058) from the consumer;
(b) refer consumers to the TPA or MADÆs designee who do not utilize
services or the full
amount of allocated services on the PCSP for 90 consecutive days. Documentation
must be in the consumerÆs file
demonstrating that a consumer has not utilized the full amount of hours
allocated on the PCSP; and
(c) submit a personal care transfer/closure form (MAD 062) to the TPA or
MADÆs designee to
close out a consumerÆs personal care services who has passed away.
[8.315.4.16 NMAC - Rp 8 NMAC 4.MAD.738.11 & 12, 7/1/04; A, 8/13/04]
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 14
8.315.4.17 PRIOR APPROVAL AND UTILIZATION REVIEW: All medicaid services
are subject to
utilization review for necessity and program compliance. Reviews by MAD
or its designee and/or the TPA may be
performed before services are furnished, after services are furnished, before
payment is made, or after payment is
made. See 8.302.5 NMAC, Prior Approval And Utilization Review. Once enrolled,
personal care providers receive
instructions and documentation forms necessary for prior approval and claims
processing.
A. The agency must obtain an approved PCSP with a prior authorization number
from the consumer,
issued by the TPA or MADÆs designee to ensure the consumer has been
approved to receive personal care services;
B. PCO services must be included in the consumerÆs PCSP and must be
approved by the TPA.
Services for which prior approval was obtained remain subject to utilization
review at any point in the payment
process. Agencies/consumers may be reviewed/audited by MAD, UR or MADÆs
designee at anytime to determine
that need, delivery of service and quality of care are being met;
C. Prior approval of services does not guarantee that individuals are eligible
for medicaid. Personal
care agencies must verify that individuals are eligible for medicaid at
the time services are furnished; and
D. An agency that does not agree with prior approval denials or other review
decisions made by the
TPA or MADÆs designee may:
(a) request a re-review or reconsideration pursuant to medicaid oversight
policies, 8.350.2 NMAC,
Reconsideration of Utilization Review Decisions [MAD-953]; and,
(b) is responsible for submitting the additional information and medical
justification to the third-party
assessor or MADÆs designee and adhering to the timelines as out lined
in medicaid oversight policies, 8.350.2
NMAC, Reconsideration of Utilization Review Decisions[MAD-953].
E. A consumer who does not agree with prior approval denials or other review
decisions made by the
TPA or MADÆs designee may request a fair hearing pursuant to 8.352.2
NMAC, Recipient Hearings.
[8.315.4.17 NMAC - Rp 8 NMAC 4.MAD.738.13, 7/1/04]
8.315.4.18 TRANSFER PROCESS: A consumer wishing to transfer services to
another medicaid approved
personal care agency may do so, for any reason, once within a plan year
or when moving to another county without
prior approval from MAD or its designee. All other transfers within the
plan year may be requested by the
consumer, but must be approved by MAD or its designee prior to the agency
providing PCO services to the
consumer. Transfers may only be initiated by the consumer and may not be
requested by the attendant as a result of
an employment issue. The consumer must give the reason for the requested
transfer. A consumer requesting more
than one transfer which is not related to moving to another county within
a plan year will be sent to MAD or its
designee by the TPA for processing.
A. A transfer requested by a consumer may be denied by MAD or its designee
for the following
reasons:
(1) the consumer is requesting more hours;
(2) the consumerÆs attendant or family member is requesting the transfer;
(3) the consumer has requested 3 or more transfers within a six-month period;
(4) the consumer wants their legal guardian, spouse or attorney-in-fact
to be their attendant who has
previously been denied by MAD or its designee;
(5) the consumer wants an individual to be their attendant who has not successfully
passed a
nationwide criminal history screening;
(6) the consumer wants an attendant who has been terminated from another
agency for fraudulent
activities;
(7) the attendant does not want to complete the mandated trainings under
the consumer-delegated
model; and
(8) the consumer does not wish to comply with the medicaid or PCO program
policies and
procedures.
B. MAD or its designee will notify the consumer, the TPA and both the originating
agency and the
receiving agency of its decision. MAD or its designee has 15 working days
after receiving the request from the
TPA, to make a decision.
C. A consumer who does not agree with MAD or its designeeÆs decision
may request a fair hearing
pursuant to 8.352.2 NMAC, Recipient Hearings. The originating agency is
responsible for the continuance of PCO
services throughout the fair hearing process.
D. The following is the process for submitting a transfer request:
(1) The consumer must inform both the agency he/she is currently receiving
services from
(originating agency) and the agency he/she would like to transfer to (receiving
agency) about the transfer request.
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 15
(2) The receiving agency must contact the originating agency to discuss
and agree on a transfer date
in which the receiving agency will begin services and the originating agency
will end services. Agencies should
factor in, at a minimum, 10 workings days for the TPA to process the paperwork.
Originating agencies are not
responsible for submitting paperwork to the TPA or MADÆs designee
to close services when transferring a consumer
to another agency.
(3) The receiving agency is responsible for completing the personal care
transfer/closure form (MAD
062) and ensuring the consumer/personal representative has signed and dated
the form.
(4) The receiving agency should mail the signed MAD 062 to the originating
agency for signature.
All three original signatures must be present for the TPA or MADÆs
designee to process the transfer.
(5) The originating agency must sign and mail the MAD 062, along with a
copy of the consumers
current PCSP (MAD 058), to the receiving agency within 48 hours of receiving
the form. If the originating agency
is disputing the transfer request for any reason, the agency should mark
ôdisputing transferö on the agency signature
line and mail the MAD 062 to the receiving agency.
(6) The receiving agency must mail the MAD 062 to the TPA or MADÆs
designee for processing;
(7) The TPA or MADÆs designee will issue a new prior authorization
number to the receiving agency
with new dates of service and units remaining for the remainder of the PCSP
year. The TPA or MADÆs designee
will notify the consumer, by giving the consumer a revised PCSP to give
to the receiving agency.
(8) The consumer is responsible for providing the receiving agency with
the revised PCSP.
(9) The TPA or MADÆs designee is responsible for tracking the number
of transfer requests submitted
by a consumer. If the TPA or MADÆs designee determines that the consumer
has exceeded the allowable number of
transfers, or has received a transfer request marked ôdisputing transferö
the TPA or MADÆs designee will mail the
transfer request to MAD or its designee for approval or denial.
[8.315.4.18 NMAC - N, 7/1/04]
8.315.4.19 DISCHARGE PROCESS: The agency may discharge a consumer for a
justifiable reason by
means of a thirteen (13)-day written notice to the consumer and MAD or its
designee. The notice must include the
consumerÆs right to a request a fair hearing and must include the
justifiable reason for the agenyÆs decision to
discharge.
A. A justifiable reason for discharge may include:
(1) staffing problems (i.e., excessive request for change in attendants
(three (3) or more in a 30-day
period);
(2) a consumer who demonstrates a pattern of verbal/physical abuse of attendants
or agency
personnel, (i.e., use of vulgar/explicit language, verbal or physical sexual
harassment, excessive use of force, verbal
or physical intimidating threats); the agency or attendant must have documentation
demonstrating the pattern of
abuse; the agency may also discharge a consumer if the life of an attendant
or agencyÆs staff member is believed to
be in immediate danger;
(3) a consumer and/or family member who demonstrates a pattern of uncooperative
behavior (i.e., not
complying with agency or medicaid policy; not allowing the agency to enter
the home to provide services; continued
requests to provide services not approved on the PCSP); the agency or attendant
must have documentation
demonstrating a pattern of uncooperative behavior;
(4) illegal use of narcotics or alcohol abuse; and
(5) fraudulent submission of timesheets.
B. The agency must provide the consumer with a current list of medicaid-approved
personal care
agencies that service the county in which the consumer resides. The agency
must assist the consumer in the transfer
process and must continue services throughout the transfer process. If the
consumer does not elect another agency,
in the 13-day time frame, the current agency must continue services until
MAD or its designee can arrange for the
consumerÆs services to continue through another agency. The agency
may not ask the TPA or MADÆs designee to
close the consumerÆs PCO services.
C. A consumer has a right to appeal the agencyÆs decision to suspend
services as outlined in 8.352.2
NMAC, Recipient Hearing Policies. A recipient has 90 days from the date
of the suspension notice to request a fair
hearing.
[8.315.4.19 NMAC - N, 7/1/04]
8.315.4.20 REIMBURSEMENT: A medicaid-approved personal care agency will
process billings in
accordance with the following:
MAD-MR:04-28 OTHER LONG TERM CARE SERVICES EFF:8-13-04
PERSONAL CARE OPTION SERVICES
8.315.4 NMAC 16
A. Agencies must submit claims for reimbursement on the HCFA-1500 claim
form or its successor.
See 8.302.2 NMAC, Billing for Medicaid Services. Once enrolled, agencies
receive instructions on documentation,
billing, and claims processing. Claims must be filed per the billing instructions
in the medicaid manual. Personal
care agencies must use ICD-9 diagnosis codes when billing for medicaid services.
B. Reimbursement for personal care services is made at the lesser of the
following:
(1) the providerÆs billed charge;
(2) the MAD fee schedule for the specific service or procedure; or
(3) the agencyÆs billed charge must be its usual and customary charge
for services.
(4) ôusual and customary chargeö refers to the amount an individual
provider charges the general
public in the majority of cases for a specific service and level of service.
[8.315.4.20 NMAC - Rp 8 NMAC 4.MAD.738.14, 7/1/04]
8.315.4.21 OTHER:
A. An attendant may not act as the consumerÆs personal representative,
in matters regarding medical
treatment, financial or budgetary decision making, unless the attendant
is the consumerÆs legal guardian, agent under
a power of attorney, conservator, or representative payee and has received
authorization to be the consumerÆs
attendant pursuant to Paragraph (7) of Subsection A of 8.315.4.10 NMAC,
Paragraph (10) of Subsection B of
8.315.4.10 NMAC, Paragraph (5) of Subsection D of 8.315.4.10 NMAC, Paragraph
(20) of Subsection A of
8.315.4.11 NMAC, and Paragraph (5) of Subsection C of 8.315.4.11 NMAC. If
the agency questions whether the
consumer is able to direct his/her own care, an agency must make a referral
to an appropriate social service or legal
agency(s) for assistance.
B. A consumer who does not comply with the requirements for receiving personal
care services may
be denied such a service or have those services suspended. A consumer has
the right to appeal this decision as
outlined in the medicaid oversight policy, 8.352.2 NMAC, Recipient Hearings.
C. An agency wishing to advertise or conduct any type of community outreach
for the PCO program
must first get prior approval from MAD or its designee before conducting
any such activity. An agency conducting
any such activity without prior approval from MAD or its designee may be
subject to a civil monetary penalty
and/or have its medicaid provider participation agreement (MAD 335) terminated
for conducting such activity
without prior approval.
D. An agency may not deceive or misrepresent information to a potential
personal care consumer.
An agency conducting any such activity may be subject to a civil monetary
penalty and/or termination of its
provider participation agreement (MAD 335). This includes:
(1) contacting consumer who are receiving services through another medicaid
program, including
personal care;
(2) door-to-door solicitation of potential consumers;
(3) making false promises;
(4) misinterpreting medicaid policies/procedures/eligibility; and
(5) representing itself as an entity to which it has no affiliation.
[8.315.4.21 NMAC - Rp 8 NMAC 4.MAD.738.15, 7/1/04; A, 8/13/04]
HISTORY OF 8.315.4 NMAC:
History of Repealed Material:
8 NMAC 4.MAD.738, Personal Care Services - Repealed 7/1/2004.