CurrentNew Mexico Health Care AuthorityPolicy N/A

Community Benefit (Home and Community Based Services) — Coverage Criteria

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Defines New Mexico Centennial Care's Community Benefit (CB) program — agency-based and self-directed HCBS models — eligibility, services, enrollment, and program responsibilities for members and managed care organizations.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyCommunity Benefit (Home and Community Based Services) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewJan 13, 2021

Next Review DateN/A

Key ActionContact the member's MCO to request an assessment to determine Community Benefit eligibility based on Nursing Facility Level of Care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2CB delivery models (ABCB and SDCB)

120 daysABCB prerequisite time

2+ ADLsNF LOC functional requirement

See §7.4Continuous NF LOC referenced

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Community Benefit (Home and Community Based Services) — Coverage Criteria

Customize your policy alerts

Sign up for all New Mexico Health Care Authority policy alerts

Know when New Mexico Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyCommunity Benefit (Home and Community Based Services) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewJan 13, 2021

Next Review DateN/A

Key ActionContact the member's MCO to request an assessment to determine Community Benefit eligibility based on Nursing Facility Level of Care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2CB delivery models (ABCB and SDCB)

120 daysABCB prerequisite time

2+ ADLsNF LOC functional requirement

See §7.4Continuous NF LOC referenced

Community Benefit Coverage Criteria

Community Benefit Eligibility

Covered when ALL of the following are met

CB eligibility: Member is a New Mexico resident with full Medicaid coverage or has a waiver category of eligibility through the allocation process; member meets Nursing Facility Level of Care (NF LOC) criteria and requires daily assistance with two or more activities of daily living; member has an MCO assessment determining eligibility for Community Benefit.

Beginning in January 2019, certain CB members may be eligible for continuous NF LOC approval per Managed Care Policy Manual §7.4 (may not require annual NF LOC reassessment). Non-Medicaid individuals must place their name on the Central Registry and await allocation.

Self-Directed Community Benefit Conditions

SDCB participation conditions

SDCB prerequisites and responsibilities: Member must have participated in Agency-Based Community Benefit (ABCB) for at least 120 calendar days before switching to the Self-Directed Community Benefit (SDCB) model; member must select a support broker contracted with or employed by the member's MCO and have an MCO care coordinator to assist in managing SDCB services; member must designate an Employer of Record (EOR) (the EOR may be the member or another individual, but the EOR may not be paid for EOR duties);>= 120 calendar days in ABCB before SDCB

All SDCB members must use a Fiscal Management Agency (FMA) contracted by MCOs to manage financial tasks (view approved care plan and budget, hire/fire/pay providers); a member may submit a written request to hire a family member and the MCO will determine if that family member meets criteria to be paid.

Community Benefits are intended to supplement natural supports and support community living; they are not intended to provide 24-hour care to the member.

Coding and Eligibility Thresholds

ABCB to SDCB transition — 120-day ABCB prerequisite

RequirementMember must have participated in the Agency-Based Community Benefit (ABCB) model for at least 120 calendar days before switching to the Self-Directed Community Benefit (SDCB).

ScopeApplies to Centennial Care members seeking to move from ABCB to SDCB.

Source notePolicy states the 120-day ABCB participation requirement begins prior to SDCB enrollment.

Functional requirement for NF LOC

Functional thresholdMember must require daily assistance with two or more activities of daily living (ADLs) to meet Nursing Facility Level of Care (NF LOC).

ContextThis NF LOC functional requirement is part of the Community Benefit eligibility criteria for Centennial Care, alongside residency and coverage requirements.

Provider Responsibilities and Enrollment Actions

Prior Authorization

Assessment required for CB eligibility

Members seeking Community Benefit (CB) services must contact their MCO to request an assessment; the MCO assessment will determine eligibility based on Nursing Facility Level of Care (NF LOC). Non‑Medicaid individuals must place their name on the Central Registry and await allocation.

Assessment determines NF LOC eligibility and need for daily assistance with two or more ADLs.
Non‑Medicaid applicants must contact Aging & Long Term Services Resource Center to be placed on the Central Registry and wait for waiver allocation.

Step Therapy

ABCB participation prerequisite (120 days)

Members must participate in the Agency Based Community Benefit (ABCB) model for at least 120 calendar days before they are eligible to switch to the Self‑Directed Community Benefit (SDCB) model.

The 120‑day ABCB requirement is mandatory prior to SDCB enrollment.

Background and Policy Purpose

The Community Benefit (CB) program is Centennial Care's Home and Community Based Services (HCBS) alternative to institutional long-term care. It is available to eligible New Mexico members who meet the Nursing Facility Level of Care (NF LOC) and who require daily assistance with activities of daily living. The program is designed to support community living by supplementing natural supports through two delivery models: agency-based (ABCB) and self-directed (SDCB).

Members seeking CB services must be assessed by their MCO to determine eligibility based on NF LOC and functional need; non-Medicaid individuals must be placed on the Central Registry and await allocation before enrollment.

Key Definitions

Community Benefit (CB)

DefinitionCommunity Benefit (CB) is Centennial Care's name for Home and Community Based Services (HCBS).

PurposeAllows eligible members to receive care in their home or community as an alternative to placement in a long-term care facility.

LimitationsIntended to supplement natural supports and support community living; not intended to provide 24-hour care to the member.

Self-Directed Community Benefit (SDCB)

Model descriptionSelf-Directed Community Benefit (SDCB) allows eligible members to direct their own care and services.

Member responsibilitiesSDCB members must select a support broker, have an Employer of Record (EOR), work with an MCO care coordinator, and use the FMA for financial management and timesheet authorization.