Medically Fragile, AIDS and AIDS-Related Complex, Disabled and Elderly (D & E), Developmental Disabilities (DD)
To help New Mexico recipients receive appropriate services, MAD has obtained a waiver of certain federal regulations in order to provide Waiver programs to recipients as an alternative to institutionalization.
Disabled & Elderly (D&E) Waivers: Effective September 1, 2007, we will only accept the Supplemental Hours Plan of Care Form. Any requests for supplemental homemaker hours received September 1, 2007, and later will be returned for information to complete the new form.
Levels of Care:
Medically Fragile, AIDS, and D & E Waivers: Medicaid UR reviews the levels of care annually.
DD Waiver: Medicaid UR reviews the level of care every third year (case managers are responsible for the remaining two years).
Appropriate forms for requesting levels of care:
Medically Fragile Waiver: Use form DOH-378; this waiver is based on meeting the medically fragile criteria.
AIDS and D & E Waivers: Use form ISD-379; review is based on meeting the nursing facility criteria.
DD Waiver: Use form MAD-378; criteria for meeting this level of care are based on the ICF-MR criteria.
Emergency Allocations:
For the D & E Waiver, requests for emergency allocation are routed through LTC Link; requests are then reviewed by Medicaid UR to determine if they meet the criteria necessary for emergency allocation. This process moves the client ahead on the waiting list for the Waiver.
Individual Service Plans:
Medicaid UR is responsible for entering approved ISPs (Individual Service Plans) for all four Waivers into the Omnicaid system. All plans are submitted to Medicaid UR on form MAD-046 with appropriate HIPAA-compliant codes. A copy of the approved MAD-046 is returned to the case management agency with the authorization (PA) number.
Waivers received 8/27/07 will no longer have the MAD-046 returned but a notification letter with the authorization (PA) number will be sent to the case management agency.
- Medically Fragile Waiver: Plans received by Medicaid UR have already been approved; they are entered into Omnicaid and the MAD-046 is returned to the case management agency with the PA number.
Waivers received 8/27/07 will no longer have the MAD-046 returned but a notification letter with the authorization (PA) number will be sent to the case management agency. - AIDS/ARC Waiver: Plans received by Medicaid UR have already been approved; they are entered into Omnicaid and the MAD-046 is returned to the case management agency with the PA number.
Waivers received 8/27/07 will no longer have the MAD-046 returned but a notification letter with the authorization (PA) number will be sent to the case management agency. - D & E Waiver: We are responsible for reviewing the clinical necessity and appropriateness of services on the ISP. Services are requested on form MAD-046 and are reviewed against the Service Standards established by the Department of Health and the documentation provided in support of the plan.
- DD Waiver: We are responsible for reviewing outlier services, awake staffing, and changes to residential status. These services are measured against the Service Standards and the documentation provided.
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