N.M. Admin. Code § 8.326.10.9

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

Section 8.326.10.9 - BISF ELIGIBILITY REQUIREMENTS

Enrollment into the BISF, as a non-entitlement program, is on a voluntary basis and occurs in up to six month increments. To be eligible for the BISF program, an applicant with a crisis need must meet the following requirements:

A.Diagnosis: Individuals are eligible for BISF services if they have a qualifying diagnosis of brain injury of ABI or TBI which has been documented in writing by a duly licensed medical professional or psychologist. A qualifying diagnosis of brain injury is confirmed by the licensed health practitioner's assignment of the current international classification of diseases (ICD) code.

B.Residency: Eligible individuals must be legal residents of the state of New Mexico. Eligible participants must be able to produce documentation of the physical location of their New Mexico residence. Those residing in an institution or are in the process of transitioning to an institutional setting are not eligible for services through the BISF program. Those participants who have a confirmed discharge date from an institutional setting and are transitioning into the community are eligible for BISF services for a 30-day period prior to the planned discharge date to assist with setting up needed supports and services. For homeless participants with brain injury, the physical address constitutes the agreed-upon location at which the participant routinely meets with the BISF service coordinator and at least one other community case manager, if available.

C.Service Coordination Duplication: Those participants served by other service coordination programs, care coordination or case management systems are not eligible to receive service coordination through the BISF program, unless transitioning between programs and with HSD approval. Such programs might include comparable services offered through any of the following:

(1) medicaid managed care organization (MCO), including community benefit;

(2) medicaid home and community-based services waivers;

(3) early and periodic screening, diagnosis and treatment;

(4) family infant toddler;

(5) program of all-inclusive care for the elderly (PACE);

(6) health management organizations (HMOs); and

(7) other private insurances.

D.Determination of eligibility: The service coordination contractor is responsible for determining eligibility for the BISF program and maintaining documentation of eligibility status. Proof of eligibility status including current qualifying ICD codes must be provided to the HSD or its designee upon request.

E.Re-enrollment into the BISF for reactivation of services: Former program participants, who disenrolled from the program due to resolution of their crisis needs, may seek to re-enroll in the BISF, in the event that a new crisis arises with which they require the program's assistance. Re-enrollment allows for the reactivation of service coordination and BISF HCBS without providing a new ICD code, in the event that a qualifying code continues to be on file.

F.Continuation of BISF services beyond one consecutive service year. Program participants who have not experienced a resolution of their crisis need(s) within two consecutive six month interims of service may be eligible to continue service coordination or BISF HCBS for additional interim periods for up to another service year as funding allows. The petition for continuation of services requires written justification by the service coordination agency, following the standards established by HSD. In no case will continuation of services be permitted without written approval by HSD to extend services beyond one service year.

G.Disenrollment from the BISF: Disenrollment from the BISF may be voluntary or involuntary.

(1)Voluntary disenrollment: Participants may voluntarily disenroll from the program without cause at any time. In addition, participants are no longer eligible to receive service coordination or BISF HCBS services when any of the following apply:

(a) other responsible payer sources have been identified and have begun coverage;

(b) the crisis or crises that caused the participant to seek enrollment have been resolved; or

(c) upon a permanent move out of the state of New Mexico. The service coordination agency will give such participants reasonable advance notice of pending disenrollment and continue furnishing any needed services until the terms for disenrollment have been met and the disenrollment is complete. Upon disenrollment, all services will be inactivated.

(2)Involuntary disenrollment: Participants of the BISF may be disenrolled involuntarily if any of the following circumstances apply, subsequent to reasonable efforts of the service coordination agency to provide technical assistance to improve the participant's understanding of program expectations and as noted below:

(a) The participant refuses to act in accordance with the requirements of their independent living plan (ILP) or otherwise participate in the resolution of their crisis needs, exercising the capabilities that remain within their power or that of their authorized representative. This describes participants who repeatedly fail to follow through with keeping appointments with the service coordinator or access needed and recommended services;

(b) The participant refuses to act in accordance with the program's participant rights and responsibilities, as explained by the service coordination agency and signed by the participant upon program intake;

(c) The participant's physical, behavioral, psychosocial or service needs exceed that which can be reasonably provided by the program or be met with available funding;

(d) The participant engages in disruptive or threatening behavior. This describes a participant whose behavior jeopardizes his or her health or safety, or the safety of others. In these cases, and with justifiable cause for the service coordinator's safety, the service coordination agency may elect to disenroll such participant without providing further remedy or technical assistance.

(e) Prior to disenrollment for any of the above, the service coordination agency proposing to disenroll a participant involuntarily is required to:

(i) document the reasons for proposing to disenroll the participant as well as any and all efforts to remedy the situation; and

(ii) submit the written request to involuntarily disenroll the participant to HSD, along with supporting documentation for HSD's review and determination that the service coordination agency has provided acceptable grounds for the participant's disenrollment.

N.M. Admin. Code § 8.326.10.9

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