N.M. Admin. Code § 8.326.10.13

Current through Register Vol. 35, No. 17, September 10, 2024

Section 8.326.10.13 - BRAIN INJURY SERVICES FUND HOME AND COMMUNITY-BASED SERVICES

BISF home and community-based services (HCBS) and goods are for outpatient care administered within the state of New Mexico and must address the participant's assessed needs and include the expectation of individual and family participation. BISF HCBS are designed to resolve a participant's identified crisis, enhance the individual's self-determination and promote independence. BISF HCBS funding can only be used for services and goods that are documented in the participant's ILP and or substantiated by physician's orders or other required documentation, as appropriate. As the payer of last resort, BISF funding may be used for the purchase of authorized services or goods that are not covered by medicaid, medicare, the special education-individuals with disability education act (IDEA) program, department of vocational rehabilitation (DVR), private insurance or other responsible payer sources. The delivery of all BISF HCBS will be in accordance with the standards set by HSD.

A.BISF HCBS eligibility requirements: BISF HCBS can only be provided to program participants who have a current BISF service coordinator and have met BISF program requirements. Eligibility for BISF HCBS is based upon the service coordinator's assessment of participant needs, verification that no responsible payer source exists, and receipt of supporting medical documentation, as appropriate to justify the need for a requested service or good. Referrals for qualifying participants are submitted to the FIA, who arranges and pays for authorized goods and services in 90-day increments.

B.Funding limits per participant: There is a maximum yearly and lifetime coverage for eligible participants as determined by their assessed needs. Funding is also limited by legislative or departmental appropriation. Coverage limitations for qualifying participants are as follows:

(1) No more than the annual budgetary cap per participant as prescribed by HSD, unless through approved written exception by HSD; this value represents a maximum amount that may be budgeted and is not a guaranteed annual budget assignment.

(2) $75,000 lifetime maximum for combined services and goods;

(3) $10,000 lifetime limit on environmental modifications; and

(4) only one emergency housing assistance per participant in a lifetime, unless an exception is made in writing by the BISF program manager at the HSD.

C.Duration of services: BISF HCBS funding and approved services are provided in six month increments with the following provisions:

(1) BISF HCBS are provided as funding limits allow only until other responsible payer sources are available, or the crisis has been otherwise resolved.

(2) BISF HCBS can only be continued for one additional interim, up to one year with documentation that the needs being addressed still exist and cannot be provided by another responsible payer. Continuation of BISF HCBS for requested services is contingent upon completion of a six-month written recertification conducted by the participant's service coordinator in accordance with program standards. As applicable, this will include orders from a physician or licensed medical provider stating support for ongoing services.

(3) BISF HCBS may be extended or continue past the six-month duration, until a necessary product can be obtained or in the case of environmental modification and retrofit automobile services, the modification to the participant's environment or automobile can be completed. Any cause for delay must be recorded by the service provider in the participant's record and provided to the service coordination agency. The record must be updated, until completion of the project or modification has been completed or the goods ordered are delivered.

(4) Exceptions to the six-month interim timeline beyond two consecutive interims, may be requested by the service coordination agency in writing through HSD's process for extending services and referrals on the basis of one or more unresolved crises, ongoing participant needs and available funding.

(5) After a participant's BISF HCBS have been inactivated, services may be reestablished through the BISF service coordinator due to an exacerbated condition or situation that has caused a critical need that cannot be covered by other responsible payer sources.

(6) Participants who are receiving BISF HCBS may be eligible to access additional BISF HCBS funding, beyond the prescribed limits, if the person has experienced a sudden, drastic and accelerated change in needs impacting health and safety, such as an exacerbated medical or psychological condition. Participants accessing BISF HCBS on an escalated basis will require medical documentation to establish a higher order of need. Escalated services may or may not be provided as funding allows on a short-term basis, per program requirements.

D.Freedom of choice: Each participant receiving BISF HCBS shall be informed of all available service providers, vendors or contractors that are eligible to provide the needed services or goods in their region. The participant shall be the sole decision maker of who is to provide services or goods from all eligible entities that could fill his or her needs. The BISF program cannot guarantee that all services will be available in all regions or that a preferred provider will agree to work with the program.

E.Service descriptions: Services that require physician's orders include but are not limited to home health aide, nursing services, neuropsychological evaluations, novel or unconventional therapies, durable medical equipment over $250, and other non-standard services and goods. Requested services and goods cannot be accessed until authorized in writing by the FIA, who arranges and pays for approved BISF HCBS and goods. BISF HCBS funding may be used to pay for services and goods that meet the noted criteria in the following categories, with special requirements, as noted:

(1)Assistive technology assessment services: Assistive technology assessment services are the systematic application of technologies to assist persons diagnosed with brain injury to improve communication skills and the ability to perform activities of daily living. An assistive technology assessment is required to justify the purchase of assistive technology or adaptive equipment that is needed to address symptoms of the participant's brain injury. Services shall be provided by an individual or agency with a minimum of a master's degree in assistive technologies; an individual or agency certified by the rehabilitation engineering and assistive technologies society of North America (RESNA); an individual or agency demonstrating a working knowledge of assistive technologies; or a licensed physician or rehabilitation provider agency. Services shall include assessment, recommendations and training by a qualified healthcare professional.

(2) Durable medical equipment and assistive technology: Durable medical equipment (DME) refers to any equipment that is used to serve a medical purpose or provides therapeutic benefits to a patient in need because of certain medical conditions, related to a participant's brain injury. Assistive or adaptive technology refers to any "product, device, or equipment, whether acquired commercially, modified or customized, that is used to maintain, increase, or improve the functional capabilities" of a person living with brain injury. DME or adaptive equipment is intended to fill the assessed medical, therapeutic or functional needs of participant and a prescription and a written assessment provided by a physician or licensed therapist must be submitted to justify the equipment requested if the cost of the DME is more than $250.

(3)Environmental modifications: Environmental modifications refer to alterations required to make the participant's home more accessible because of their brain injury and related physical limitations. Environmental modifications include but are not limited to, widening doorways, installing ramps and modifying bathrooms. Funds cannot be used to cover home improvements; expenses related to home maintenance or other repairs that would otherwise be incurred as a responsible homeowner or tenant; or be applied toward the purchase of a home. The following criteria for environmental modifications must be adhered to:

(a) An assessment for the proposed environmental modification must be done by a licensed physical or occupational therapist to justify the service.

(b) For any modification over $250, contractor bids must be obtained by the service coordinator which must include blueprint, written description of plan and price itemization for materials and labor, along with any other supporting documentation.

(c) Only contractors with a current license in good standing can be engaged to do environmental modifications.

(d) Funds for environmental modifications are limited to a $10,000 lifetime maximum.

(e) The participant shall provide proof of property ownership, and, if residing in or renting property owned by another party, provide written permission from the landlord prior to pursuing any BISF funded environmental modification;

(f) The FIA in collaboration with the participant's service coordinator shall show evidence that BISF funding was the most appropriate payer source to fund the requested environmental modification;

(g) For instances when costs related to a needed environmental modification cannot be covered in total by another funding source, documentation of collaboration with other funding sources must be submitted to the FIA and include:

(i) a detailed description and plan for the project including total cost;

(ii) the specific portion to be funded by the BISF program as the payer of last resort; and

(iii) the contractor's written acknowledgment of the specific portion and amount of the project for which the BISF program is responsible.

(h) All requests, plans and related documentation for environmental modifications shall be submitted by the BISF service coordinator for review and written approval by HSD, prior to submitting a referral.

(4)Home health aide, homemaker or companion: A home health aide, homemaker or companion from a licensed agency may be contracted to assist participants in gaining functional independence with activities of daily living, performance of general household tasks, and enable the eligible participant to accomplish tasks he or she would normally do for himself or herself if he or she did not have a brain injury. Providers of these services must meet the quality personnel standards as stipulated by the agency and state licensing. The required license of contractors providing these services must be in good standing and current. Provision of authorized services must adhere to the following requirements:

(a) Participants must require regular assistance with activities and or instrumental activities of daily living, as prescribed by the HSD BISF program.

(b) Family members, who reside in the same household, cannot serve as paid caregivers, unless:

(i) the participant and family member reside in a remote area, where no professional caregiver or respite services are available, and the needs of the participant prevent the in-home caregiver from engaging in employment outside the home; or

(ii) the intensiveness of the participant's behavioral or mental health needs prevent outside caregivers from entering the home and administering effective care. These needs shall be justified in writing through a signed letter from the participant's licensed medical or mental health care providers and submitted to HSD or designated representative for review and approval. Such justification shall be updated annually, for as long as the participant remains eligible for BISF services.

(c) In-home family caregivers who meet the criteria noted in Subparagraphs (a) and (b) of Paragraph (4) of Subsection E of 8.326.10.13 NMAC must be trained and employed by a licensed agency that meets the quality personnel standards, as stipulated by the agency and state licensing, and timesheets shall be submitted, as requested.

(5)Initial and emergency housing costs: Assistance to pay initial or emergency rent, security deposit and utility start-of-service or one-month maintenance of service charges may be provided as once in a lifetime occurrence. Documentation submitted by BISF service coordinators with any housing referral to the FIA shall adhere to the guidelines below and be maintained in the participant's BISF record:

(a) a completed housing plan worksheet and budget, which includes documentation that the participant has sufficient resources to sustain ongoing housing expenses for the chosen housing; documentation that no other payer source was available to cover the housing expenses; the rental price range that would be sustainable for the participant; and detail regarding the manner in which initial housing or utility costs will be paid.

(b) a copy of a lease or rental agreement letter that contains the name of the leaser, the address of the property and a contact name and phone number for verification of rental intent.

(c) start up and or emergency utility costs shall be submitted to the FIA to be paid within 90 days of the signed rental agreement.

(6)Nursing care: Brain injury related private duty nursing services covered by BISF HCBS must be in compliance with the New Mexico Nurse Practice Act and provided in the participant's home under the orders of the participant's physician. These services may be provided by a licensed registered nurse (RN) or a licensed practical nurse (LPN).

(7)Nutritional consultation: Coverage includes consultation and follow-up with a registered dietician or nutritionist, who is licensed with the New Mexico board of nutrition and dietetics; qualified providers may include specialists such as MDs, DOs, Ph.D.s, RDs, LDs, or DCs.

(8)Physician or medical provider services for outpatient health insurance: Coverage of copayments for physician services or the treatment of a participant's brain injury or conditions directly related to the brain injury requires treatment verification by the office of the licensed medical professional or therapist. Payments of insurance premiums and or deductibles are not covered by the BISF program.

(9)Prescribed medications: Copayment assistance may be used to cover prescription medications that are medically necessary to treat symptoms arising from a participant's brain injury or directly related conditions. Reimbursement for this service requires adherence to the following guidelines:

(a) prescription medications eligible for reimbursement must be listed in the approved BISF program formulary. Exceptions to the BISF program formulary must be approved in writing from the HSD BISF program manager or designee;

(b) participants may not be reimbursed for prescription medications in cases where the receipt evidencing purchase is submitted more than 90 days past the date the prescription was filled;

(c) the participant must submit the pharmacy print out, which identifies the participant's name, the date, doctor's name, name of the medication and the price paid; and

(d) if feasible, and the FIA is able to set up an agreement with certain pharmacies, participants may have scripts filled with the billing sent directly to the FIA for payment; the service coordinator is responsible for checking receipts submitted by participants to avoid duplicate payments on those submitted through the pharmacy.

(10)Professional life skills coaching and organizer services: This interim service may be accessed to assist a participant in learning or re-learning life skills that are required in order to function independently in their home environment, in their job or in their community. These services are provided by individuals with appropriate certification and require the provider to address the cognitive, behavioral or social impairments that are preventing the return to independent functioning. The service may include assistance with home organization or management, time management, records management, and organization and management of finances, as well as coaching in appropriate social interactions; effective communication skills; anger management; self-care/health management; pursuit of education or employment; childcare and parenting skills; accessing and navigating community resources; mindfulness training and any other cognitive, social, or behavioral skills identified in the participant's ILP. The services of the life skills coach are not to be used as a substitute for the participant's task performance. The services are customized for each participant and are usually provided in the person's home, place of work or wherever an activity would normally occur. Services are to be provided at a frequency that will best facilitate the transfer of needed skills, following an evaluation conducted by the coach. Life skills may also be provided to family members to help them adjust to their changed roles and circumstances following the brain injury of their family member. Service limitations apply as prescribed by HSD.

(11)Respite care: A participant's primary caregiver may be provided temporary respite, if the caregiver lives in the same household as the participant. Respite may be provided for a period up to 72 hours per week and may or may not include overnight hours. BISF HCBS funds cannot be used to pay for respite care provided by home health aides or salaried employees.

(12) Retrofit automobile: This service is used to modify an automobile specifically for the use of a participant with brain injury. The service is limited to installation of a van lift; hand or pedal controls; and modified seating. Funds cannot be used for the purchase of an automobile or be applied toward the cost of auto repairs or maintenance that would be otherwise incurred by the responsible vehicle owner or lessee. Any request for retrofit of an automobile will begin with a referral by the service coordinator identifying a certified driver rehabilitation specialist (CDRS), who will assess the abilities of the participant with brain injury, complete an evaluation, make recommendations for the vendor who will perform the installation, and provide any training on the use of specialized equipment or controls, once the installation is completed. The CDRS may or may not be affiliated with the vendor who completes the installation; a separate referral may be needed for the vendor completing the installation.

(13)Transportation (public or private): Requests to cover private or public in-state transportation for participants with brain injury must adhere to the following guidelines:

(a) Funds may be authorized for mileage reimbursements for the use of the participant's private vehicle for the purpose of getting to medical and therapy care for treatment of conditions directly related to the brain injury. Approved mileage reimbursements will:

(i) require prior approval by the BISF service coordinator for identified destinations and be authorized for payment by the BISF FIA;

(ii) cover costs of actual mileage at no more than the current state approved rates;

(iii) not be authorized to pay for gas, mileage or wear and tear on any other vehicle not privately owned by the participant with brain injury;

(iv) not cover overnight costs for participant or caregiver lodging or per diem; and

(v) not be covered for requests submitted more than 90 days past the date the transportation was provided, or the trip was taken.

(b) Funds may be used to purchase public transportation in the form of bus, van or rail passes for participants and their caregivers.

(14)Therapies and alternative therapies: All therapists providing traditional and alternative therapy services must hold a current license and be in good standing from their respective licensing authority. Service limitations on alternative therapies, such as massage, acupuncture and chiropractic care may apply, as specified by the HSD. BISF HCBS funds may be used to cover copayments for medically necessary therapies, as listed below:

(a) outpatient mental or behavioral health;

(b) physical therapy;

(c) occupational therapy;

(d) speech and language therapy;

(e) massage therapy;

(f) acupuncture; and

(g) chiropractic care.

(15)Other use of BISF HCBS funds: BISF HCBS funds may be used to provide other limited services in the absence of another payer source. Those services provided by a licensed practitioner may require an order or a letter of recommendation from a licensed physician or therapist. Requests for these services must be submitted by the service coordinator in writing for written authorization by the HSD BISF program manager or designee and include:

(a) Special training and education to the participant and family in the use of tools and methods needed to promote recovery and independence of the participant.

(b) Neuropsychological evaluations to determine a course of treatment for a participant who has already met the BISF program's eligibility criteria. The participant must present a physician's order or letter of recommendation for prior authorization, before accessing the service.

(c) Special health and dietary items that are needed because of conditions directly related to the brain injury.

(d) Health and housing advocate through independent contractors or peer mentors for attendance and advocacy at medical or therapy appointments or providing assistance in locating safe and affordable housing.

F. Providers or vendors of BISF HCBS sub-contracted by the FIA may not charge program participants for services already arranged and authorized through the BISF, unless the program has authorized direct reimbursement to the participant.

G. Only the HSD BISF program manager or designee can make exceptions or waivers of requirements regarding the provision of BISF HCBS with the following stipulations:

(1) requests for waivers to the provisions and services provided by the BISF program must be made by the service coordination agency in writing;

(2) requests must have accompanying documentation justifying the exception; and

(3) written approval from HSD must be placed in the participant's record by both the FIA and the service coordination agency.

N.M. Admin. Code § 8.326.10.13

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