CurrentNew Mexico Health Care AuthorityPolicy N/A

Medically Fragile Home and Community-Based Services Waiver - Coverage Criteria

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State rule describing eligibility, provider qualifications, covered waiver services, provider responsibilities, and program structure for New Mexico's medically fragile HCBS waiver program for individuals with developmental disabilities and medically fragile conditions.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyMedically Fragile Home and Community-Based Services Waiver - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2018

Last ReviewMar 1, 2018

Next Review DateN/A

Key ActionCase manager must submit the level-of-care packet including the LTCAA to the TPA for prior authorization in a timely manner.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PermanentDuration of rule

Every other monthCase manager contact

60 daysRN supervision freq

14 daysRespite limit

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Medically Fragile Home and Community-Based Services Waiver - 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

PolicyMedically Fragile Home and Community-Based Services Waiver - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2018

Last ReviewMar 1, 2018

Next Review DateN/A

Key ActionCase manager must submit the level-of-care packet including the LTCAA to the TPA for prior authorization in a timely manner.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PermanentDuration of rule

Every other monthCase manager contact

60 daysRN supervision freq

14 daysRespite limit

$5,000/5yrEnv. mod. limit

Coverage Criteria and Service Limits

inv-01: Enrollment and Ongoing Eligibility

Enrollment and ongoing eligibility are contingent upon meeting medical and financial criteria and the availability of program slots. Covered when ALL of the following are met:

MFW Enrollment Criteria: Applicant meets financial criteria and belongs to an eligible category; applicant meets the level of care (LOC) required for admittance to an ICF/IID; applicant has a developmental disability, developmental delay, or is at risk of developmental delay; applicant has a medically fragile condition diagnosed before age 22 as defined by the rule; a funding allocation/unduplicated recipient (UDR) position is available.

Ongoing eligibility is determined annually and is subject to funding and UDR availability.

inv-02: Case Management Coverage and Requirements

Case management services are covered and must include the following duties:

Case Management Duties: Identify medical, social, educational, family and community support resources; schedule and coordinate timely interdisciplinary team (IDT) meetings to develop and modify the ISP annually and as needed; document contacts with the recipient and providers; verify eligibility on an annual basis; ensure the medically fragile long-term care assessment abstract (LTCAA) is completed and signed by an authorized clinician; submit the LOC packet including the LTCAA to the third-party assessor (TPA) contractor for prior authorization in a timely manner; ensure the waiver review form (MAD 046) is submitted timely (annually and as needed); initiate ongoing monitoring to evaluate delivery, effectiveness and appropriateness of services; perform an annual recipient satisfaction survey; coordinate MFW services with other sources (state plan, FIT, commercial insurance, education and community).

Face-to-face contact at least every other month; monthly telephonic or electronic contact.

inv-03: Home Health Aide & Private Duty Nursing Coverage

Home health aide and private duty nursing services are covered as expanded EPSDT benefits for waiver participants under age 21 and as waiver services for eligible recipients:

Home Health Aide Services: Provided in the recipient's home or community; provide total care or assist with activities of daily living (ADLs) including bathing, hygiene, toileting, transfers, ambulation, range of motion, feeding support and related tasks; perform simple procedures as extensions of therapy, bowel and bladder care, ostomy site care, assistance with self-administered medications, reporting changes in patient condition, household services essential to health at home, and basic non-invasive nursing assistant skills.

Must be provided by licensed agencies and aides who completed required training and competency testing; RN supervision and documentation as required by program standards.

Private Duty Nursing Services: Provided in the recipient's home and community; include medication management and administration and teaching, aspiration precautions, gastrostomy/jejunostomy feeding management, skin and wound care, urinary catheter management, bowel and bladder care, infection control, oxygen management, seizure management and precautions, nutrition management, health education, staff supervision, and behavior and self-care assistance.

Agencies must employ only RNs and LPNs licensed in New Mexico; covered under the state plan as expanded EPSDT for recipients under age 21.

inv-04: Eligibility and Prior Approval

Covered when ALL of the following are met

MFW eligibility and authorization: Recipient requires an ICF/IID level of care (LOC) and meets eligibility requirements defined in Subsection B of Section 8.314.3.12 NMAC; LOC determinations are made by MAD or its designee; the ISP must specify the type, amount and duration of services; certain procedures or services specified in the ISP may require prior approval from MAD or its designee; services approved remain subject to utilization review.

Prior approval of services does not guarantee MAP eligibility; providers must verify recipient MAP eligibility at time services are furnished and determine if other health insurance exists.

inv-05: Individualized Service Plan (ISP)

ISP requirements (must be followed for service coverage)

ISP development and content: The ISP is person-centered and developed annually through a case manager-led person-centered planning process with the IDT; the case manager obtains information on strengths, needs, preferences, desired outcomes, health status and risk factors and completes required assessments (including the CIA and annual LOC redetermination); the ISP must address ADL assistance needs, health care needs, equipment needs, relationships, personal safety, provider responsibilities, and include a budget within the capped dollar amount (CDA).

Implementation begins when provider service plans are received and the plan and budget are approved by the TPA contractor; therapy treatment plans must be initiated and updated at least every six months when therapy services are provided.

ISP monitoring and revisions: The case manager monitors ISP pre-planning and development, conducts monthly monitoring via phone, electronic and face-to-face contacts, and the IDT reviews the ISP at least annually or more often as needed to assess progress and make revisions; the case manager initiates IDT meetings and ensures ISP compliance with MF waiver service standards.

Revisions occur when personal goals, needs or life circumstances change; the case manager assures provider responsibilities, back-up plans, and submission to the TPA contractor as required.

inv-06: Service Details and Limits

Service-specific coverage details and limits

Skilled therapy services: Physical, occupational, and speech-language therapy services are covered and may include assessments, evaluations, treatment interventions, training, assistive technology design/modification, and collaboration with other providers; waiver therapy is available when state plan therapy limits are exhausted and therapy plans must be updated at least every six months.

Adults access state plan therapy for acute/temporary conditions; waiver covers therapy when state plan limits are exhausted.

Respite care: Respite services are provided in the recipient's home, a provider's private residence, or a specialized foster care home and include medical and non-medical care, personal care, household assistance, assistance with enteral feedings as appropriate, positioning, ambulation and transfer skills, arranging transportation, and ensuring health and safety; respite is limited to 14 days or 336 hours per budget year.14 days / 336 hours per budget year

Recipient or authorized representative chooses respite location.

Environmental modifications:

No explicit exclusions are listed in the excerpted portion of this document. The policy text in this section focuses on provider qualifications and responsibilities rather than enumerating separate exclusion items.

Environmental modification services cover purchases and installations necessary to ensure the health, welfare, safety, or access of the eligible recipient (examples include ramps, widened doorways, specialized plumbing/electrical, lifts, air filtration, alarms, and mobility tracks). Excluded are adaptations or improvements of general utility that are not of direct medical or remedial benefit and additions that increase total square footage except when required to complete an adaptation. These services must comply with applicable building codes and are limited to $5,000 every five years.

Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the state plan; medical equipment and supplies that are furnished by the state plan are not covered under waiver services. The waiver explicitly excludes nutritional or dietary supplements and disposable items such as diapers, bed pads, and disposable wipes from coverage.

Providers must follow applicable coding manual guidelines and CMS correct coding initiatives and are responsible for ensuring claims are billed correctly. The policy expressly requires providers to avoid improper unbundling or upcoding. Failure to adhere to these coding and billing requirements may lead to noncompliance actions or payment issues, including potential recoupment.

Only services that are listed as covered waiver services are funded under the waiver program. Ancillary services may be available through the state Medicaid (MAP) plan, but those services remain subject to the state plan's limitations and coverage restrictions and are not automatically covered by waiver funds.

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Submit LOC packet with LTCAA to TPA for prior authorization

Case managers must submit the level-of-care (LOC) packet, including the medically fragile long-term care assessment abstract (LTCAA) completed and signed by the physician/PA/CNP, to the third-party assessor (TPA) contractor for prior authorization in a timely manner.

Ensure LTCAA is completed and signed by physician, physician assistant or clinical nurse practitioner before submission.
Include the LTCAA as part of the LOC packet sent to the TPA for prior authorization.

Prior Authorization

Obtain MAD/designee prior approval for select ISP services

Certain procedures or services specified in the Individualized Service Plan (ISP) require prior approval from MAD or its designee; even when prior approval is granted, those services remain subject to utilization review at any point in the payment process.

Request MAD/designee prior approval for ISP-specified procedures/services when indicated.

Key Definitions

Medically Fragile — definition of medically fragile individuals and care needs

DefinitionA chronic physical condition resulting in prolonged dependency on medical care requiring daily skilled nursing intervention; may involve frequent acute exacerbations needing medical supervision or physician consultation, frequent time-consuming specialized treatments, or dependence on medical technology (e.g., ventilators, dialysis, enteral/parenteral nutrition, supplemental oxygen).

Diagnostic timingMedically fragile condition must be diagnosed prior to age 22 for Medically Fragile Waiver (MFW) eligibility.

Clinical consequencesWithout daily skilled nursing intervention or necessary medical technology, a reasonable level of health could not be maintained and hospitalization may be required during exacerbations.

Home and community-based services (HCBS) waiver — definition describing CMS waiver use and purpose

DefinitionA set of MAD services that provides alternatives to long-term institutional care by offering an array of home- and community-based options; CMS waives certain Social Security Act requirements to permit these waiver programs.

Program Background

The medically fragile population comprises individuals with chronic physical conditions that produce prolonged dependence on medical care and frequent need for skilled nursing interventions; many rely on medical technology such as ventilators, enteral nutrition, or continuous oxygen. The waiver is intended to provide home- and community-based alternatives to institutional ICF/IID level of care, supporting health, safety, and independent function through services like private duty nursing, home health aide care, therapy, environmental adaptations, and case management. Eligibility requires meeting ICF/IID level of care criteria and other program-specific requirements, and services are provided within the limits and procedures established by the waiver.

Policy Revision History

2018-03-01rule_effective_dateLatest

NMAC Part 3 Medically Fragile Home and Community-Based Services waiver rule issued/replaced and became effective.

2018-03-01rule_issuance

Issuing agency recorded as New Mexico Human Services Department with rule text and scope defined in Sections 8.314.3.1–8.314.3.3 NMAC.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyMedically Fragile Home and Community-Based Services Waiver - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2018

Last ReviewMar 1, 2018

Next Review DateN/A

Key ActionCase manager must submit the level-of-care packet including the LTCAA to the TPA for prior authorization in a timely manner.

SourceLink

On This Page

Purchasing and installing adaptations necessary for health, welfare, safety or access to the home, including ramps, widened doorways, plumbing/electrical modifications, lifts, alarm or air filtration systems, installation of specialized plumbing/electrical systems for medical equipment, and other specified adaptations; excluded are adaptations that are general utility improvements or additions of total square footage except when necessary to complete an adaptation.

All modifications must meet applicable building codes and standards; costs of maintenance and upkeep are included; items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the state plan.

Recognize approvals may be time- or condition-limited and remain subject to subsequent utilization review.

Step Therapy

Anticipate utilization review for MFW services

All Medicaid services, including MFW services, are subject to utilization review for medical necessity and program compliance; reviews may be pre-service, post-service pre-payment, or post-payment.

Prepare for utilization review at any stage of the payment process.
Follow documentation and submission instructions provided after enrollment to support reviews.

Documentation Required

Maintain complete records and submit required forms timely

Providers must maintain records sufficient to fully disclose the extent and nature of services; case managers must document contacts, verify eligibility annually, ensure the LTCAA is completed and signed, submit the LOC packet and MAD 046 waiver review form timely, and monitor implementation.

Maintain records per Section 8.302.1 NMAC to fully disclose services provided.
Document face-to-face contacts (at least every other month), monthly telephonic/electronic contacts, and all provider/recipient contacts.
Submit LOC packet (including LTCAA) and MAD 046 waiver review form in a timely manner.

Documentation Required

Document nursing care, incidents, and ISP monitoring

Private duty nursing agencies must document nursing assessments, observations, treatments, nursing interventions, incidents of harm, medication errors, and any noncompliance with the ISP; case managers must document ISP development, provider service plans, and monitor ISP implementation monthly.

Document all nursing activities and any incidents or medication events as part of the recipient's record.
Case managers must monitor the ISP monthly via phone, electronic contact, and face-to-face visits and record monitoring activities.

Denial Risk

Verify MAP eligibility and follow MAD rules to avoid denials/recoupment

Failure to verify MAP (Medicaid) eligibility at the time services are furnished or to follow MAD provider rules, coding guidelines, and correct coding initiatives may trigger noncompliance actions, denials or recoupment.

Verify recipient MAP eligibility at time of service and check for other health insurance prior to furnishing services.
Adhere to MAD provider rules, coding manual guidelines, and CMS correct coding initiatives to avoid improper unbundling or upcoding.

Denial Risk

Prior approval denials and reconsideration process

Prior approval requests can be denied; providers may request a re-review and reconsideration per Section 8.350.2 NMAC, and prior approval does not guarantee MAP eligibility or payment.

If prior approval is denied, submit a request for re-review/reconsideration as outlined in Section 8.350.2 NMAC.
Understand that obtaining prior approval does not ensure MAP eligibility or final payment—continue to verify eligibility and comply with utilization review.

Note

Follow MFW provider & case management duties and monitoring requirements

Case managers and providers must follow all actionable steps in the MFW provider responsibilities and case management duties: comply with MAD/DOH rules and billing instructions, conduct required face-to-face and monthly contacts, ensure documentation and LTCAA completion, and conduct internal quality monitoring of ISPs.

Comply with federal/state laws, MAD provider participation agreement, DOH provider agreement, MAD provider rules manual, MFW service standards, and billing instructions.
Case manager duties include identifying supports, scheduling IDT meetings, developing/modifying the ISP annually or as needed, and monitoring ISP pre-planning and development.
Conduct internal quality improvement monitoring and ensure ISP implementation begins when provider service plans are received and the TPA approves plan and budget.

PurposeTo enable delivery of services in home and community settings as an alternative to institutional long-term care (e.g., the medically fragile waiver program).

AuthorityOperates under a CMS 1915(c) waiver allowing HSD to provide home- and community-based supports through MAD.

Level of care (LOC) — definition specifying LOC requirement (ICF/IID LOC) for program eligibility

DefinitionThe level of care (LOC) an eligible recipient must meet to qualify for the medically fragile program; eligibility requires meeting an ICF/IID LOC as defined in the rule.

DeterminationLOC determinations are used to establish eligibility for MFW and are made according to the program's criteria (ICF/IID level required).

Role in authorizationRecipient must meet ICF/IID LOC and other eligibility criteria for enrollment and prior authorization of waiver services.

Home health aide — definition of home health aide duties and activities of daily living assistance

DefinitionHome health aide services are provided in the recipient's home or community to provide total care or assist with activities of daily living (ADLs), including bathing, hygiene, toileting, transfers, ambulation, range of motion, feeding assistance, and related tasks.

Allowed activitiesPerform simple procedures as extensions of therapy, bowel and bladder care, ostomy site care, personal care, ambulation and exercise, household services essential to health at home, assistance with self-administered medications, reporting changes in patient conditions, and completing records.

Supervision and trainingMust be provided by licensed agencies and aides who complete required training and competency testing; RN supervision is required at least every 60 days with documentation.

Private duty nursing — definition covering RN/LPN services such as medication management, gastrostomy care, wound care

DefinitionPrivate duty nursing services are RN/LPN-delivered services provided in the recipient's home and community for physical conditions, illnesses, or chronic disabilities, covering assessment, treatment, and nursing interventions.

Included servicesMay include medication management and teaching; aspiration precautions; gastrostomy/jejunostomy feeding management; skin, wound and urinary catheter care; bowel and bladder care; infection control; oxygen and seizure management; nutrition management; health education and screening; anxiety reduction; staff supervision; and behavior and self-care assistance.

Provider requirementsPrivate duty nursing agencies must employ only RNs and LPNs licensed in New Mexico and meet DOH standards required by contracting arrangements.