Section 12. Supports Waiver Contracted Entities And Providers

Services are to be provided in the least restrictive manner. The HSD does not allow for the use of any restraints, restrictive interventions, or seclusions to an eligible supports waiver recipient. The following resources and services have been established to assist eligible recipients to access supports waiver services through the agency-based service delivery model or the participant directed service delivery model. These include the following: A. Community supports coordinator (CSC) services: CSC services are direct services intended to assist the eligible recipient in attaining and maintaining medical and financial eligibility; educating, guiding and assisting the eligible recipient to make informed planning decisions about service and supports; developing an ISP through a person-centered planning process; implementing and monitoring the ISP and AAB; and under the agency- based service delivery model, arranging for, directing, and managing supports waiver services and supports. B. Financial management agency (FMA): For eligible recipients selecting the participant directed service delivery model, the FMA acts as the intermediary between the eligible recipient and the MAD payment system and assists the eligible recipient or the EOR with employer-related responsibilities. The FMA pays employees and vendors based upon an approved AAB. The FMA assures there is eligible recipient and program compliance with state and federal employment requirements and monitors and makes available to the eligible recipient the reports related to utilization of services and budget expenditures system and assists the eligible recipient or the EOR with employer-related responsibilities. The FMA pays employees and vendors based upon an approved AAB. The FMA assures there is eligible recipient and program compliance with state and federal employment requirements and monitors and makes available to the eligible recipient the reports related to utilization of services and budget expenditures. Based on the eligible recipient’s approved ISP and AAB, the FMA must: (1) verify that the recipient is eligible for MAD services prior to making payment; (2) receive and verify all required employee and vendor documentation; (3) establish an accounting for each eligible recipient’s AAB; (4) process and pay invoices for goods, services and supports approved in the ISP and the AAB and supported by required documentation; (5) process all payroll functions on behalf of the eligible recipient and EORs including: (a) collect and process timesheets of employees; (b) process payroll, withholding, filing, and payment of applicable federal, state and local employment-related taxes and insurance; and (c) track and report disbursements and balances of the eligible recipient’s AAB and provide a monthly report of expenditures and budget status to the eligible recipient and their CSC, and quarterly and annual documentation of expenditures to the MAD; (6) receive and verify employee and vendor agreements, including collecting required provider qualifications; 8.314.7 NMAC 6 (7) monitor hours, the total amounts billed for all goods and services during the month; (8) process and report on employee background checks; (9) answer inquiries from the eligible recipient and solve problems related to the FMA responsibilities; and (10) report to the CSC provider, MAD and DOH any concerns related to the health and safety of an eligible recipient, or if the eligible recipient is not following the approved ISP and AAB. C d for all goods and services during the month; (8) process and report on employee background checks; (9) answer inquiries from the eligible recipient and solve problems related to the FMA responsibilities; and (10) report to the CSC provider, MAD and DOH any concerns related to the health and safety of an eligible recipient, or if the eligible recipient is not following the approved ISP and AAB. C. Third-party assessor (TPA): The TPA or MAD’s designee is responsible for determining medical eligibility through a LOC assessment, approving the ISP, and authorizing an eligible recipient’s annual budget in accordance with 8.314.7 NMAC and the supports waiver service standards. The TPA: (1) determines medical eligibility using the LOC criteria in 8.314.7.9 NMAC; determinations are completed initially for an eligible recipient who is newly enrolled in the supports waiver and thereafter at least annually for currently enrolled supports waiver eligible recipients. The TPA may re-evaluate LOC more often than annually if there is an indication that the eligible recipient’s medical condition or LOC has changed; and (2) approves the ISP and the annual budget request resulting in an AAB, at least annually or more often if there is a change in the eligible recipient’s circumstances, in accordance with this NMAC and supports waiver service standards. D. Conflict of interest: An eligible recipient’s CSC may not serve as the eligible recipient’s EOR, authorized representative or personal representative for whom they are the CSC. A CSC may not be paid for any other services utilized by the eligible recipient for whom they are the CSC, whether as an employee of the eligible recipient, a vendor, an employee or subcontractor of an agency. A CSC may not provide any other paid supports waiver services to an eligible recipient unless the recipient is receiving CSC services from another agency sentative for whom they are the CSC. A CSC may not be paid for any other services utilized by the eligible recipient for whom they are the CSC, whether as an employee of the eligible recipient, a vendor, an employee or subcontractor of an agency. A CSC may not provide any other paid supports waiver services to an eligible recipient unless the recipient is receiving CSC services from another agency. The CSC agency may not provide any other direct services for an eligible recipient that has an approved ISP, an approved budget, and is actively receiving services in the supports waiver program. The CSC agency may not employ as a CSC any immediate family member or guardian for an eligible recipient of the supports waiver program that is served by the CSC agency. A CSC agency may not provide guardianship services to an eligible recipient receiving CSC services from that same agency. The CSC agency may not provide any direct support services through any other type of 1915 (c) developmental disabilities waiver program. A CSC agency shall not engage in any activities in their capacity as a provider of services to an eligible recipient that may be a conflict of interest. As such a CSC agency shall not hold a business or financial interest in an affiliated agency that is paid to provide direct care for any eligible recipients receiving supports waiver services. An affiliated agency is defined as a direct service agency providing supports waiver services that has a marital, domestic partner, blood, business interest or holds financial interest in providing direct care for eligible recipients receiving supports waiver services. Affiliated agencies must not hold a business or financial interest in any entity that is paid to provide direct care for any eligible recipients receiving home and community-based services (HCBS). Any direct service agency or CSC agency that has been referred to the DOH internal review committee (IRC) or is on a moratorium will not be approved to provide supports waiver services s waiver services. Affiliated agencies must not hold a business or financial interest in any entity that is paid to provide direct care for any eligible recipients receiving home and community-based services (HCBS). Any direct service agency or CSC agency that has been referred to the DOH internal review committee (IRC) or is on a moratorium will not be approved to provide supports waiver services. [8.314.7.12 NMAC - N, 4/1/2021] 8.314.7.13 QUALIFICATIONS FOR ELIGIBLE INDIVIDUAL EMPLOYEES, INDEPENDENT PROVIDERS, PROVIDER AGENCIES, AND VENDORS: A. Agency-based service delivery model requirements for individual employees, independent providers, provider agencies and vendors: All supports waiver eligible providers under the agency-based model of service delivery must be approved by the DOH or its designee and have an approved MAD and DOH provider agreement. MAD through its designee, DOH/DDSD, must ensure that its subcontractors or employees meet all required qualifications. The provider agency must provide oversight of subcontractors and supervision of employees to ensure that all required MAD and DOH/DDSD qualifications; compliance with EVV requirements; all requirements outlined in the supports waiver services standards, applicable New Mexico administrative code (NMAC) rules, MAD supplements, and as applicable, the provider’s New Mexico licensing board’s scope of practice and licensure are met. B. Participant directed service delivery model requirements for individual employees, independent providers, and vendors: In order to be approved to provide services under the participant directed service delivery model, provider agency, employees, vendors, or an independent provider, including non-licensed personal care or direct support worker, must meet the general and service specific qualifications set forth in this rule initially and continually meet licensure requirements as applicable, and submit an employee or vendor enrollment packet, specific to the provider or vendor type, for approval to the FMA odel, provider agency, employees, vendors, or an independent provider, including non-licensed personal care or direct support worker, must meet the general and service specific qualifications set forth in this rule initially and continually meet licensure requirements as applicable, and submit an employee or vendor enrollment packet, specific to the provider or vendor type, for approval to the FMA. In addition, to be an authorized provider for the supports waiver and receive payment for delivered services, the provider must complete a vendor or 8.314.7 NMAC 7 employee provider agreement and all required tax documents. The provider must have credentials verified by the eligible recipient or the employee of record (EOR) and the FMA. The provider agency is responsible to ensure that all agency employees meet the required qualifications. Individual employees may not provide more than 40 hours of services in a consecutive seven-day work week. (1) prior to rendering services to an eligible supports waiver recipient as a personal care or direct support worker, respite worker, customized community supports worker, or employment worker, an individual seeking to provide these services must complete and submit a nature of services questionnaire to the FMA. The FMA will determine, based on the nature of services questionnaire if the relationship is that of an employee or an independent contractor; (2) an authorized CSC provider must have a MAD approved provider participation agreement (PPA) and the appropriate approved DOH/DDSD agreement. C idual seeking to provide these services must complete and submit a nature of services questionnaire to the FMA. The FMA will determine, based on the nature of services questionnaire if the relationship is that of an employee or an independent contractor; (2) an authorized CSC provider must have a MAD approved provider participation agreement (PPA) and the appropriate approved DOH/DDSD agreement. C. General Qualifications agency-based and participant directed service delivery model providers: (1) individual employees, independent providers, provider agencies, excluding CSC provider agencies, who are employed by a community supports waiver recipient to provide direct services shall: (a) be at least 18 years of age; (b) be qualified to perform the service and demonstrate capacity to perform required tasks; (c) be able to communicate successfully with the eligible recipient; (d) pass a nationwide caregiver criminal history screening pursuant to NMSA 1978, Section 29-17-2 et seq. and 7.1.9 NMAC and an abuse registry screen pursuant to NMSA 1978, Section 27-7a-1 et seq. and 8.11.6 NMAC; (e) complete all trainings as required by DOH/DDSD and complete training specific to the eligible recipient’s needs as identified in the approved ISP; (f) for participant directed, training needs on items identified in the individual service plan (ISP), and the training plan is determined by the eligible recipient or their legal representative for any training specific to the employee in addition to trainings required by DOH/DDSD; the eligible recipient is also responsible for providing and arranging for employee training and supervising employee performance; training expenses for paid employees cannot be paid for with the eligible recipient’s AAB; and (g) meet any other service specific qualifications, as specified in 8.314.7 NMAC and service standards specific to the employee in addition to trainings required by DOH/DDSD; the eligible recipient is also responsible for providing and arranging for employee training and supervising employee performance; training expenses for paid employees cannot be paid for with the eligible recipient’s AAB; and (g) meet any other service specific qualifications, as specified in 8.314.7 NMAC and service standards. (2) vendors, including those providing professional services: (a) shall be qualified to provide the service; (b) shall possess a valid business license, if applicable; and (c) are required to follow the applicable licensing regulations set forth by the profession; refer to the appropriate New Mexico board of licensure for information regarding applicable licenses; (3) qualified and approved relatives and legal guardians may be hired as employees and paid for the provision, of supports waiver services except for CSC services, customized community supports group services, non-medical transportation services for a minor, environmental modifications services, vehicle modifications services, behavior support consultation services, assistive technology and employment supports. A spouse may not provide transportation for adult participants. A relative or legal guardian may not provide services that the legal responsible individual would ordinarily perform in the household for individuals of the same age who did not have a disability or chronic illness. A relative or legal guardian may not provide services that the legally responsible individual would ordinarily perform in the household for individuals of the same age who did not have a disability or chronic illness; (4) once enrolled, providers, vendors and contractors receive a packet of information from the eligible recipient or FMA including billing instructions, and other pertinent materials A relative or legal guardian may not provide services that the legally responsible individual would ordinarily perform in the household for individuals of the same age who did not have a disability or chronic illness; (4) once enrolled, providers, vendors and contractors receive a packet of information from the eligible recipient or FMA including billing instructions, and other pertinent materials. MAD makes available on the HSD/MAD website, on other program-specific websites, or in hard copy format, information necessary to participate in health care programs administered by HSD or its authorized agents, including program rules, billing instructions, utilization review instructions, and other pertinent materials. When enrolled, an eligible recipient or legal representative, or provider, vendor or contractor receives instruction on how to access these documents. It is the responsibility of the eligible recipient or legal representative, or provider, vendor, or contractor to access these instructions or ask for paper copies to be provided, to understand the information provided and to comply with the requirements. The eligible recipient or legal representative, or provider, vendor, or contractor must contact HSD or its authorized agents to request hard copies of any program rules manuals, billing and utilization review instructions, and other pertinent materials and to obtain answers to questions on or not covered by these materials; 8.314.7 NMAC 8 (a) no provider of any type may be paid in excess of 40 hours within the established work week for any one eligible recipient or EOR when applicable; (b) no provider agency is permitted to perform both LOC assessments and provide any services for the eligible recipients; (c) providers may market their services but are prohibited from soliciting eligible recipients under any circumstances. (5) Employer of record: The EOR is the individual responsible for directing the work of the eligible recipient’s employees under the participant directed service delivery model ency is permitted to perform both LOC assessments and provide any services for the eligible recipients; (c) providers may market their services but are prohibited from soliciting eligible recipients under any circumstances. (5) Employer of record: The EOR is the individual responsible for directing the work of the eligible recipient’s employees under the participant directed service delivery model. The EOR may be the eligible recipient or a legal representative of the recipient. A recipient through the use of the support’s waiver EOR questionnaire will determine if an individual meets the requirements to serve as an EOR. The recipient’s CSC will provide him or her with the questionnaire. The questionnaire shall be completed by the recipient with assistance from the CSC upon request. The CSC shall maintain a copy of the completed questionnaire in the recipient’s file. The EOR does not have budget authority. When utilizing both vendors and employees, an EOR is required for oversight of employees and to sign payment request forms for vendors. The EOR must be documented with the FMA whether the EOR is the eligible recipient or a designated qualified individual. (a) an eligible recipient that is the subject of a plenary or limited guardianship or conservatorship may not be their own EOR; (b) a power of attorney or other legal instrument may not be used to assign EOR responsibilities, in part or in full, to another individual and may not be used to circumvent the requirements of the EOR as designated in 8.316.7 NMAC; (c) a person under the age of 18 years may not be an EOR; (d) an EOR who lives outside New Mexico shall reside within 100 miles of the New Mexico state border. If the eligible recipient wants to have an EOR who resides beyond this radius, the eligible recipient must obtain written approval from the DOH prior to the EOR performing any duties he requirements of the EOR as designated in 8.316.7 NMAC; (c) a person under the age of 18 years may not be an EOR; (d) an EOR who lives outside New Mexico shall reside within 100 miles of the New Mexico state border. If the eligible recipient wants to have an EOR who resides beyond this radius, the eligible recipient must obtain written approval from the DOH prior to the EOR performing any duties. This written approval must be documented in the ISP; (e) the eligible recipient’s provider may not also be their EOR; (f) an EOR whose performance compromises the health, safety or welfare of the eligible recipient, may have their status as an EOR terminated; (g) an EOR must be a legal representative if not the recipient; and (h) an EOR may not be paid for any other services utilized by the eligible recipient for whom they are EOR, whether as an employee of the eligible recipient, a vendor, or an employee or contractor of an agency. An EOR makes important determinations about what is in the best interest of the eligible recipient and should not have any conflict of interest. An EOR assists in the management of the eligible recipient’s budget and should have no personal benefit connected to the services requested or approved in the budget. D. Qualifications of assistive technology providers and vendors: Must hold a current business license issued by the state, county or city government. E. Qualifications of behavior support consultation providers: Behavior supports consultation provider agencies shall have a current business license issued by the state, county or city government, if required. Behavior supports consultation provider agencies shall comply with all applicable federal, state, and waiver rules and procedures regarding behavior support consultation, and must ensure that provider training is in accordance with the DOH/DDSD training policy supports consultation provider agencies shall have a current business license issued by the state, county or city government, if required. Behavior supports consultation provider agencies shall comply with all applicable federal, state, and waiver rules and procedures regarding behavior support consultation, and must ensure that provider training is in accordance with the DOH/DDSD training policy. Providers of behavior support consultation must maintain a current New Mexico license with the appropriate professional field licensing body and have a minimum of one year of experience working with individuals with intellectual or developmental disabilities. Providers of behavior support consultation services must possess qualifications in at least one of the following areas: (1) licensed clinical psychologist, licensed psychologist associate, (masters or Ph.D. level); (2) licensed independent social worker (LISW) or a licensed clinical social worker (LCSW); (3) licensed master social worker (LMSW); (4) licensed mental health counselor LMHC); (5) licensed professional clinical counselor (LPCC); (6) licensed marriage and family therapist (LMFT); or (7) licensed practicing art therapist (LPAT). F. Qualifications of the community support coordinator providers: In addition to general requirements, a CSC provider shall ensure that all individuals hired, or contracted for CSC services meet the criteria specified in this section in addition to all applicable rules and service standards (LPCC); (6) licensed marriage and family therapist (LMFT); or (7) licensed practicing art therapist (LPAT). F. Qualifications of the community support coordinator providers: In addition to general requirements, a CSC provider shall ensure that all individuals hired, or contracted for CSC services meet the criteria specified in this section in addition to all applicable rules and service standards. Community supports coordinators shall: (1) be at least 21 years of age; 8.314.7 NMAC 9 (2) possess a bachelor’s degree in social work, psychology, human services, counseling, nursing, special education or related field; or have a minimum of six-years direct experience related to the delivery of social services to people with disabilities; (3) have at least one year of experience working with people with disabilities or I/DD; (4) complete all trainings as required by DOH/DDSD; (5) verification of provider qualifications; and (6) pass a national care giver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6 NMAC. G. Qualifications for customized community supports individual providers: For individual community supports providers the worker must meet the following requirements: (1) be 18 years of age or older; (2) demonstrate the capacity to perform required tasks; (3) be able to communicate successfully with the eligible recipient; (4) complete all training requirements as required by DOH/DDSD; and (5) pass a national care giver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6 NMAC; and (6) meet any other service qualifications, as specified in the regulations. H successfully with the eligible recipient; (4) complete all training requirements as required by DOH/DDSD; and (5) pass a national care giver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6 NMAC; and (6) meet any other service qualifications, as specified in the regulations. H. Qualifications for customized community supports group providers: Provider agencies must meet requirements including a business license, accreditation with the commission on accreditation of rehabilitation facilities (CARF) international, employment and community services or the council on quality and leadership, quality assurances, financial solvency, training requirements, records management, quality assurance policy and processes. The agency staff must meet the following requirements: (1) be at least 18 years of age; (2) have at least one year of experience working with people with disabilities; (3) be qualified to perform the service and demonstrate capacity to perform required tasks; (4) be able to communicate successfully with the eligible recipient; (5) pass a national care giver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6 NMAC. (6) complete specific training based on needs identified in the ISP and by the recipient; and (7) meet any other service qualifications, as specified in the regulations. I. Qualifications of personal care service providers: In addition to general MAD requirements, the direct support providers must meet additional qualifications specific to the type of services provided. Provider agencies must be homemaker/personal care agencies certified by the MAD or its designee or a homemaker/personal care agency holding a New Mexico homemaker/personal care agency license ions. I. Qualifications of personal care service providers: In addition to general MAD requirements, the direct support providers must meet additional qualifications specific to the type of services provided. Provider agencies must be homemaker/personal care agencies certified by the MAD or its designee or a homemaker/personal care agency holding a New Mexico homemaker/personal care agency license. A homemaker/personal care agency must hold a current business license when applicable, and meet financial solvency, training, records management, and quality assurance rules and requirements. Personal care direct support workers must: (1) be at least 18 years of age; (2) demonstrate capacity to perform required tasks; (3) be able to communicate successfully with the eligible recipient; (4) complete all trainings as required by DOH/DDSD; and (5) pass a national care giver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6 NMAC. J. Qualifications of employment supports providers: (1) A job developer, whether an agency or individual provider, must: (a) be at least 21 years of age; (b) complete all training requirements by DOH/DDSD; (c) have a high school diploma or GED; (d) pass a national care giver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27a-4 et seq oyment supports providers: (1) A job developer, whether an agency or individual provider, must: (a) be at least 21 years of age; (b) complete all training requirements by DOH/DDSD; (c) have a high school diploma or GED; (d) pass a national care giver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6 NMAC; (e) have experience in developing and using job and task analysis; (f) have knowledge of the Americans with Disabilities Act (ADA); 8.314.7 NMAC 10 (g) have knowledge and experience working with the department of vocational rehabilitation (DVR) office; and (h) have experience with or knowledge of the purposes, functions, and general practices of entities such as department of labor navigators one-stop career centers, business leadership network, chamber of commerce job accommodation network, small business development centers, retired executives, local business community agencies, and DDSD resources. (2) Job coaches whether agency or individual provider, must: (a) be at least 18 years of age; (b) complete all training requirements by DOH/DDSD; (c) have a high school diploma or GED; and (d) pass a national care giver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6 NMAC. K. Qualifications of environmental modifications providers: Environmental modification providers must possess an appropriate plumbing, electrician, contractor license; appropriate technical certification to perform the modification; and, hold a current business license issued by the state, county or city government. L use registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6 NMAC. K. Qualifications of environmental modifications providers: Environmental modification providers must possess an appropriate plumbing, electrician, contractor license; appropriate technical certification to perform the modification; and, hold a current business license issued by the state, county or city government. L. Qualifications of non-medical transportation providers: Individual transportation providers must possess a valid New Mexico driver’s license with the appropriate classification, be free of physical or mental impairment that would adversely affect driving performance, have no driving while intoxicated (DWI) convictions or chargeable (at fault) accidents within the previous two years, have a current insurance policy and vehicle registration. Transportation vendors must hold a current business license and tax identification number. Each agency will ensure drivers meet the following qualifications: (1) be at least 18 years old; (2) possess a valid, appropriate New Mexico driver’s license; (3) have a current insurance policy and vehicle registration; and (4) must complete all training requirements as required by DOH/DDSD. M. Qualifications of respite providers: Respite services may be provided by eligible individual respite providers. Respite provider agencies must hold a current business license, and meet financial solvency, training, records management and quality assurance rules and requirements. In addition, for participant-directed services, the eligible recipient or their representative evaluates training needs based on the needs identified in the ISP and by the recipient, provides or arranges for training, as needed, and supervises the worker. Respite worker must: (1) be 18 years of age or older; (2) demonstrate capacity to perform required tasks; (3) be able to communicate successfully with the eligible recipient; (4) pass a nationwide caregiver criminal history screening pursuant to Section 29-17-2 et seq d on the needs identified in the ISP and by the recipient, provides or arranges for training, as needed, and supervises the worker. Respite worker must: (1) be 18 years of age or older; (2) demonstrate capacity to perform required tasks; (3) be able to communicate successfully with the eligible recipient; (4) pass a nationwide caregiver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27-7a-1 et seq. NMSA 1978 and 8.11.6 NMAC; and (5) complete all training requirements as required by DOH/DDSD. N. Qualifications of vehicle modification providers: Vehicle modification providers must possess an appropriate mechanic or body work license; appropriate technical certification to perform the modification; and, hold a current business license issued by the state, county or city government.