Long-Term Care and Community Benefit

Your Blue Cross and Blue Shield of New Mexico plan covers long-term care. There are services to help you meet health or personal needs. You may also qualify to get care at home through the Community Benefit. This type of care can help you stay independent.

Long-Term Care

Long-term care is for those who are disabled or have long-term illness. This care requires prior authorization from BCBSNM. Long-term care includes:

• Medical and non-medical care.
• Help with daily needs like dressing, bathing, and using the bathroom.
• Care that can be given at home, in the community, in assisted living or nursing homes.

People can need long-term care at any age. If you need nursing care, the Community Benefit may provide options.

Community Benefit

You may be eligible for the Community Benefit:

• If you meet certain Medicaid requirements.
• Based on medical need for programs that are offered through the New Mexico Health Care Authority (HCA).

To find out if you are eligible, a Care Coordinator will assess your level of care. You will qualify if the assessment shows you need a certain level of care. If you need care from a nursing facility, you are eligible. Learn more about care coordination.

Those who qualify for this benefit have options. They can choose either the Agency-Based or the Self-Directed Community Benefit.

Agency-Based Community Benefit

This option means an agency handles your personal care. For example, a Personal Care Agency will work with you – they will help find caregivers who can best meet your needs. The agency will hire the caregivers and do background checks. You will need to work with your Care Coordinator to arrange your care. The type of care is based on your thorough needs assessment. 

Self-Directed Community Benefit

This option includes home and community-based services. Self-direction gives you choices. It also gives you control over how the services are provided. You can choose who provides your care.

If you choose the Self-Directed Community Benefit, you will need:

• An Employer of Record (EOR)
• A Care Coordinator
• A Support Broker
• An Authorized Agent (optional). You can assign someone to help. The agent you choose will have access to your medical and financial information. This is so the agent can help you to understand waiver services.

All these people will work together. They will make sure you meet all requirements. They will help with filling out forms, hiring providers, training, planning and more.

You can be the EOR or choose someone to be an EOR for you. The EOR will recruit, hire and fire all employees. The EOR will make all work schedules and assign tasks. The EOR will supervise and train all employees.

Members must work with their Care Coordinator to plan care. The type of care is based on the needs assessment.

If you want to move between the Agency-Based Community Benefit and the Self-Directed Community Benefit, please note:

• You must use agency-based services for 120 days before you can choose to move to the Self-Directed Community Benefit.
• If you are involuntarily removed from the Self-Directed Community Benefit, being reinstated is up to BCBSNM.

Check the Member Handbook to learn more about Community Benefit options. You will find more details on what is and what isn't covered by your health plan.