DraftNew Mexico Health Care AuthorityPolicy N/A

Developmental Disabilities Home and Community-Based Services Waiver (DDW) — Amendments to 8.314.5 NMAC (coverage criteria)

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Proposed amendments to New Mexico's 8.314.5 NMAC governing the DDW waiver: clarifies definitions, provider qualifications, service packages, clinical review, appeal processes, and documentation requirements for Medicaid-eligible recipients and participating providers.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyDevelopmental Disabilities Home and Community-Based Services Waiver (DDW) — amendments to 8.314.5 NMAC

Policy CodePolicy N/A

Change TypeDefinitions, service rules, procedural and review process revisions

Effective DateMar 1, 2016

Next Review DateN/A

Key ActionSubmit required clinical documentation and clinical justification supporting DDW service requests and budgets for IDT and outside reviewer evaluation.

SourceLink

POLICY UPDATE CHANGES

New and revised definitions including adult, child, authorized representative, clinical documentation, clinical justification, DDW clinical criteria, outside reviewer, and young adult.

Language throughout sections revised to clarify waiver population, services, provider qualifications, provider agreements, and Supports Intensity Scale requirements.

New process language for outside review, clinical criteria application, ISP and budget denials, agency review conferences, authorized representative, administrative hearing process, and automatic continuation of benefits with a fair hearing request.

A subsection for intensive medical living supports was moved (deleted as standalone and incorporated elsewhere).

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DraftNew Mexico Health Care AuthorityPolicy N/A

Developmental Disabilities Home and Community-Based Services Waiver (DDW) — Amendments to 8.314.5 NMAC (coverage criteria)

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyDevelopmental Disabilities Home and Community-Based Services Waiver (DDW) — amendments to 8.314.5 NMAC

Policy CodePolicy N/A

Change TypeDefinitions, service rules, procedural and review process revisions

Effective DateMar 1, 2016

Next Review DateN/A

Key ActionSubmit required clinical documentation and clinical justification supporting DDW service requests and budgets for IDT and outside reviewer evaluation.

SourceLink

POLICY UPDATE CHANGES

New and revised definitions including adult, child, authorized representative, clinical documentation, clinical justification, DDW clinical criteria, outside reviewer, and young adult.

Language throughout sections revised to clarify waiver population, services, provider qualifications, provider agreements, and Supports Intensity Scale requirements.

A subsection for intensive medical living supports was moved (deleted as standalone and incorporated elsewhere).

Background and Scope

These amendments implement a court-approved settlement (Waldrop) and make targeted revisions to New Mexico's DDW waiver rules to clarify how clinical review and service authorization are applied. The changes add and refine definitions (including DDW clinical criteria, outside reviewer, and young adult), reorganize provider qualifications and living supports language, and update procedural sections governing clinical review and appeals. The overall purpose is to ensure that requests for waiver services are evaluated against explicit clinical criteria approved by the Department of Health and applied through an independent review process, while aligning service, provider, and assessment rules with the settlement requirements.

Key Defined Terms

Key defined terms — new and updated definitions

AdultDefined as an individual 18 years of age and older for purposes of DDW waiver services.

ChildDefined as an individual under 18 years of age for purposes of DDW waiver services.

Young adultDefined as an individual between the ages of 18 through 20 years of age.

Authorized representativeAn individual designated by the eligible recipient to act on the recipient's behalf.

Clinical documentationDocumentation that demonstrates the request for DDW services.

Clinical justificationDocumentation that supports the need for services based on the eligible recipient's assessed need and DDW clinical criteria.

DDW clinical criteria / Outside reviewerDDW clinical criteria are those approved by the Department of Health (DOH) and applied by an independent outside reviewer who conducts clinical review of each DDW service.

Coverage and Medical Necessity Criteria

General medical necessity and review criteria

Covered when DDW clinical criteria are met and the request is clinically justified by documentation and IDT assessment.

Primary requirements: Recipient is eligible for the Developmental Disabilities Waiver (DDW); the requested DDW service is supported by required clinical documentation and clinical justification; the service meets DDW clinical criteria approved by the Department of Health (DOH) and applied by an outside reviewer; and the interdisciplinary team (IDT) has considered the DDW group's suggested service package and proposed budget with focus on the individual's clinically justified support needs.

DDW clinical criteria are defined by DOH and applied by an independent outside reviewer; IDT consideration of service package and budget must prioritize clinically justified supports.

Within the coverage criteria framework the proposed rule does not list explicit service exclusions in the provided excerpts. Instead, the rule mainly reorganizes and clarifies structure: several subsections are revised across Sections 9–15, and notably Subsection W is deleted with its qualifications moved into Subsection H under community living supports. This reflects structural reorganization rather than the introduction of named exclusions in the excerpted text.

The rule introduces a formal process for applying clinical criteria when an Individual Service Plan (ISP) or proposed budget is denied. Section 18 adds new language defining an outside review process and the application of DDW clinical criteria to ISP and budget denials; subsequent sections establish agency review conferences, authorized representative roles, administrative hearing steps, and automatic continuation of benefits when a fair hearing is requested. Practically, this means ISP and budget denials will be subject to independent clinical review and the administrative processes outlined in Sections 20–21 rather than unilateral administrative closure.

Provider Responsibilities, Authorization, and Documentation

Prior Authorization

Authorization via outside reviewer — allow recipient-requested outside review

When DDW clinical criteria are in question or an eligible recipient requests it, the recipient may request authorization of services through an outside reviewer; the rule revises Subsection A to clarify that eligible recipients can request services through the outside reviewer when clinical criteria are met and Subsection D defines the outside review process and application of clinical criteria for authorizations.

Recipient may request services through an outside reviewer when DDW clinical criteria are met.
Section 18 Subsection D defines the outside review process and how clinical criteria are applied to authorizations.

Step Therapy

IDT service package considerations — follow clinically justified supports over suggested package

The interdisciplinary team (IDT) must consider the DDW group's suggested service package and proposed budget but prioritize supports based on the individual’s clinically justified needs; the rule also specifies consideration of availability of three therapy disciplines and relocates intensive medical living supports into living supports guidance.