N.M. Code R. § 8.326.10.10

Current through Register Vol. 35, No. 16, August 27, 2024

Section 8.326.10.10 - BISF CONTRACTED ENTITIES AND CONTRACTORS

Brain injury services fund (BISF) services are provided through two contractor components, service coordination and fiscal intermediary agent for BISF HCBS.

A.Service coordination services: Service coordination services serve a problem-solving function. They are intended to resolve a participant's stated crisis need, ensure service continuity, prevent fragmentation of services and endeavor to tap into any and all resources that are appropriate and accessible, including community-based supports, while resolving the crisis that brought the participant into the program. The intent of service coordination is to augment, not replace, the participant's natural supports in a manner that facilitates independent living and self-determination. All participants must have a BISF program service coordinator before they can receive any other BISF program services.

(1)Qualifications for service coordination: Service coordination agencies serving the BISF program must ensure the following pertaining to staff qualifications:

(a) have a current social worker license in good standing with the New Mexico board of social work examiners; or

(b) have a current registered nurse license, in good standing from the New Mexico board of nursing; or

(c) have a bachelor's degree in social work, counseling, nursing, special education or closely related field plus one-year clinical experience related to the brain injury population working in any of the following settings:

(i) home health or community health program;

(ii) hospital;

(iii) private practice;

(iv) publicly funded institution or long-term care program;

(v) mental health program;

(vi) school or school health setting;

(vii) community-based social service program; or

(viii) other programs addressing the needs of individuals with brain injury.

(d) With prior approval from the HSD BISF program manager or designee, exceptions to service coordinator qualifications can be made; contractors requesting qualification exceptions must demonstrate that applicant candidates have relevant education, internships or volunteer experience. Other qualifications may be:

(i) associates degree and a minimum of three years of experience in the mental health or brain injury field; or

(ii) high school graduation or general educational development (GED) test and a minimum of five years of experience in the mental health or brain injury field.

(e) All BISF service coordinators whether subcontracting or employed by a BISF program contracted agency must meet these requirements and attend continuing education as determined by HSD.

(2)Scope of services: Service coordination includes but is not limited to facilitating eligibility determination for individuals applying to the BISF; conducting an in-person assessment; developing an independent living plan (ILP); coordination and documentation of the delivery of services; maintaining a complete permanent case record for each participant which includes documentation as prescribed by HSD; and creating a transition plan for discharge from the BISF program, coordinating with other case managers, as needed.

(a) Service coordinators must identify, and resolve known or suspected issues that may have an impact on the safety and well-being of the participant.

(b) Service coordinators must evaluate and monitor direct service and implementation of the ILP through face-to-face contact with the participant at a frequency prescribed by HSD.

(c) Service coordination agencies are required to maintain a 24-hour emergency response system that allows participants to contact the agency and respond to individual emergency situations within a reasonable amount of time after notification on a 24-hour basis. An emergency response written policy is to be provided to all program participants.

B.Fiscal intermediary agent (FIA): The fiscal intermediary agent (FIA) serves as the intermediary for the arrangement and payment of brain injury specific home and community-based services (HCBS). BISF services are only accessible through the coordination of a BISF program service coordination agency and are limited to filling a participant's needs as outlined in the participant's independent living plan (ILP), when there is an imminent risk to the participant's health and safety.

(1)Qualifications for FIA: FIA service staff must demonstrate the following qualifications:

(a) have a bachelor's degree in business, social work, counseling, nursing, special education or closely related field; and

(b) have experience related to the brain injury population, working in any of the following settings:

(i) home health or community health program;

(ii) hospital;

(iii) private practice;

(iv) publicly funded institution or long-term care program;

(v) mental health program; or

(vi) community-based social service program; or other program addressing the needs of individuals with brain injuries.

(c) With prior approval from the BISF program manager or designee, exceptions to FIA personnel qualifications can be made. Contractors requesting qualification exceptions must demonstrate relevant education internships or volunteer experience. Other qualifications may be:

(i) associate degree and experience in the mental health or brain injury field; or

(ii) high school graduation or general educational development (GED) test and extensive experience in the mental health or traumatic brain injury field.

(d) All BISF FIA staff employed by the agent, must meet these requirements and attend continuing education as determined by HSD. Contracted FIA service providers must have the required education and be duly licensed by the state of New Mexico within their respective disciplines.

(2)Scope of services: Fiscal intermediary agent services include but are not limited to the following activities: maintain a network of providers of brain injury related services and goods and ensure that subcontracted providers are duly licensed by the state of New Mexico or otherwise certified within their respective disciplines; procure goods and arrange contracts and letters of agreement with vendors and contractors who provide the goods, services and supports; receive service and goods referral requests submitted by BISF service coordinators for prior authorization; and arrange for delivery of BISF goods and services.

(a) Prior to arranging for and funding requested services or goods, the FIA must verify that other responsible payer source coverage is not available to pay for services or goods and that the participant has exhausted any other financial resources.

(b) The FIA must monitor and document service expenditures for participants receiving BISF HCBS and ensure that coverage does not exceed the allowable limits set by HSD;

(c) The FIA must assure that subcontracted providers and vendors are providing the services and goods as contracted and ensure timely reimbursement to such providers and vendors.

C.General administrative requirements: Agencies contracted to provide BISF service coordination or fiscal intermediary services are required to:

(1) have and follow confidentiality standards;

(2) maintain a current business license issued by the state, county or city government if required;

(3) comply with all applicable federal or state regulations, policies and procedures that apply to their business and to their contract with HSD;

(4) demonstrate financial solvency;

(5) maintain full professional liability insurance coverage;

(6) establish and maintain written policies and procedures related to:

(a) service provision and appropriate supervision;

(b) professional documentation standards;

(c) training and education on brain injury; and

(d) grievances and appeals as outlined in 8.326.10.15 NMAC in a manner that is accommodating to those living with brain injury and agreeable to the HSD BISF program; and

(7) have a governing board with at least one external member with a brain injury, a family member with a brain injury or professional working with brain injury;

(8) maintain an in-house directory of brain injury resources for each region served.

N.M. Code R. § 8.326.10.10

8.326.10.10 NMAC - N, 11/15/07, Adopted by New Mexico Register, Volume XXXII, Issue 06, March 23, 2021, eff. 4/1/2021