N.M. Admin. Code § 8.314.5.7

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.314.5.7 - DEFINITIONS

A.Activities of daily living (ADLs): Basic personal everyday activities that include bathing, dressing, transferring (e.g., from bed to chair), toileting, oral care, mobility and eating, and skills necessary to maintain the normal routines of the day such as housekeeping, shopping and preparing meals. The term also includes exercising, personal, social and community skills.

B.Adult: An individual who is 18 years of age or older.

C.Authorized representative: HSD must permit applicants and beneficiaries to designate an individual or organization to act responsibly on their behalf in assisting with the individual's application and renewal of eligibility and other ongoing communications. Such a designation must be in writing including the applicant's signature and must be permitted at the time of application and at other times. Legal documentation of authority to act on behalf of an applicant or beneficiary under state law, such as a court order establishing legal guardianship or a power of attorney, shall serve in the place of written authorization by the applicant or beneficiary. Representatives may be authorized to; sign an application on the applicant's behalf; complete and submit a renewal form; receive copies of the applicant or beneficiary's notices and other communications from the agency; and act on behalf of the applicant or beneficiary in all other matters with the agency. The power to act as an authorized representative is valid until the applicant or beneficiary modifies the authorization or notifies the agency that the representative is no longer authorized to act on their behalf, or the authorized representative informs the agency that they are no longer acting in such capacity, or there is a change in the legal authority upon which the individual's or organization's authority was based. Such notice must be in writing and should include the applicant or authorized representative's signature as appropriate. The authorized representative is responsible for fulfilling all responsibilities encompassed within the scope of the authorized representation to the same extent as the individual they represent, and must agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or beneficiary provided by the agency. As a condition of serving as an authorized representative, a provider, staff member or volunteer of an organization must sign an agreement that they will adhere to the regulations relating to confidentiality (relating to the prohibition against reassignment of provider claims as appropriate for a health facility or an organization acting on the facility's behalf), as well as other relevant state and federal laws concerning conflicts of interest and confidentiality of information (42 CFR 435.923).

D.Child: An individual under the age of 18. For purpose of early periodic screening, diagnosis and treatment (EPSDT) services eligibility, "child" is defined as an individual under the age of 21.

E.Developmental disabilities supports division (DDSD): Operating agency that oversees daily administration of New Mexico's 1915c home and community-based waiver programs.

F.Electronic visit verification (EVV): A telephone and computer-based system that electronically verifies the occurrence of selected services, as required by the 21st Century CURES Act. The EVV system verifies the occurrence of authorized service visits electronically by documenting the precise time and location where service delivery visit begins and ends. EVV is implemented according to federal requirements and timelines. The 21st Century CURES Act requires EVV for personal care services (PCS), defined as services that provide assistance with activities of daily living (ADLs) or instrumental activities for daily living (IADLs) effective January 1, 2020 and for home health services effective January 1, 2023.

G.Individual service plan (ISP): A person-centered plan for an eligible recipient that includes their needs, functional levels, intermediate and long-range outcomes for achieving their goals and specifies responsibilities for the eligible recipient's support needs. The ISP enables and assists the recipient to identify and access a personalized mix of paid waiver and non-paid services and supports that assists them to achieve personally defined outcomes in the community.

H.Person centered planning (PCP): Person centered planning is a process that places a person at the center of planning their life and supports. It is an ongoing process that is the foundation for all aspects of the DDW program and DDW service provider's work with individuals with I/DD. The process is designed to identify the strengths, capacities, preferences, needs, and desired outcomes of the recipient. The process may include other persons, freely chosen by the individual, who are able to serve as important contributors to the process. It involves person centered thinking, person centered service planning and person- centered practice.

I.Supporting documentation: Sufficient information and documentation that demonstrates the request for initial and ongoing developmental disabilities waiver (DDW) services is necessary and appropriate based on the service specific DDW clinical criteria established by the developmental disabilities support division (DDSD) for adult recipients excluding former class members of Walter Stephen Jackson, et al vs. Fort Stanton Hospital and Training School et. al, (757 F. Supp. 1243 DNM 1990). Examples of supporting documentation include but are not limited to: the DDW therapy documentation form (TDF), intensive medical living supports (IMLS) and adult nursing services parameter tools, electronic comprehensive health assessment tool (e-Chat), all other assessments, clinical notes, progress notes, interdisciplinary team (IDT) meeting minutes, letters or reports from physicians or ancillary service providers that provide sufficient clinical information that demonstrates the need for requested services, etc. Any relevant supporting information and documentation is acceptable and will be considered by the outside reviewer.

J.Third party assessor (TPA): The medical assistance division (MAD) contractor who determines level of care and medical eligibility for the developmental disabilities waiver and other 1915c waiver programs.

K.Waiver: Permission from the centers for medicaid and medicare services (CMS) to cover supports for a particular population or service not ordinarily allowed.

L.Young adult: An individual between the ages of 18 through 20 years of age who is allocated to the DDW and is receiving specific services as identified in the DOH/DDSD standards. An individual under age 21 is eligible for medical services funded by their medicaid providers under EPSDT. Upon the individual's 21^st birthday, they are considered to be an adult recipient of DDW services.

N.M. Admin. Code § 8.314.5.7

8.314.5.7 NMAC - N, 11-1-12; A, 6-15-14, Amended by New Mexico Register, Volume XXVI, Issue 02, January 30, 2015, eff. 2/1/2015, Adopted by New Mexico Register, Volume XXVII, Issue 04, February 29, 2016, eff. 3/1/2016, Adopted by New Mexico Register, Volume XXIX, Issue 22, November 27, 2018, eff. 12/1/2018, Amended by New Mexico Register, Volume XXXIII, Issue 06, March 22, 2022, eff. 4/1/2022, Amended by New Mexico Register, Volume XXXV, Issue 05, March 12, 2024, eff. 4/1/2024