2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix B. DefinitionsTerm Definition Source• Concurrent Section 1915(b) and 1915(c) Waivers: States can apply to simultaneouslyimplement two types of waivers to provide a continuum of services to the elderly andpeople with disabilities, as long as all federal requirements for both programs are met.Waiver 1115New Mexico StateInsurance Coverage-TitleXIX ComponentWaiver 1115New Mexico CoverageInsurance Title XXIComponentWaiver 1115Centennial CareWaiver 1915(b)NM Behavioral HealthWaiverWaiver 1915(b)New Mexico SaludWaiver 1915(c)NM Mi Via-ICF/MR(0448.R01.00)Waiver 1915(c)NM Mi Via NF (0449.R01.00)Waiver 1915(c)NM Medically Fragile(0223.R04.00)According to information provided by the state, this demonstration provides coverage touninsured childless adults with income from 0 up to 200% of the federal poverty level (FPL)who are unemployed, self-employed, or employed by a small employer with fewer than 50employees. Employers and employees are required to contribute to the cost of coverage. Forthe Title XXI component of the State Coverage Insurance Section 1115 demonstration thatprovides coverage to parents up to 200 percent of the FPL, please see the separate listing forthe Title XXI New Mexico State Coverage Insurance Demonstration.According to information provided by the state, this demonstration permits the state to imposea six-month waiting period for the demonstration population, which is composed of uninsuredchildren from birth through age 18, from 185% FPL up to but not including 235% FPL.According to information provided by the state, Centennial Care designed to create acomprehensive managed care delivery system in New Mexico under which contracted healthplans will offer the full array of current Medicaid services, including acute, behavioral health,home and community–based, and long-term institutional care. This proposal would combineexisting section 1915(b), 1915(c), and 1115 waivers under a comprehensive demonstrationproject. Additional waivers and expenditure authorities are requested for variousprogrammatic and financing changes, including increased cost sharing for non-emergent useof the emergency room (ER) and credits for healthy behaviors. The state also seeks tocontinue its financial support for sole community providers, and to use some of the funds tosupport projects proposed by hospitals that will support the growth of the health careinfrastructure of the state.Managed care program which provides comprehensive mental health and substance abuseservices through collaboration and partnership with a single statewide contractor.Salud! was previously the umbrella name for New Mexico's Medicaid managed care program.Salud! Services were provided by contracted MCOs to provide Medicaid services to eligibleand enrolled citizens. Clients enrolled into the Salud! program had until the 25th day of theirthird month in a Salud! MCO to change to another MCO. After the third month with the sameMCO, clients were unable to change for the next nine months. Two months before the end oftheir nine-month enrollment period, clients got a letter that let them change their MCO.Provides consultant/support guidance, customized community supports, employmentsupports, homemaker/direct support services, respite, home health aide services, skilledtherapy for adults, personal plan facilitation, assisted living, behavior support consultation,community direct support, customized in-home living supports, emergency response services,environmental mods, nutritional counseling, private duty nursing for adults, related goods,specialized therapies, transportation for individuals with autism, DD, MR ages 0 – no maxage.Provides consultant/support guidance, customized community supports, employmentsupports, homemaker/direct support services, respite, home health aide services, skilledtherapy for adults, personal plan facilitation, assisted living, behavior support consultation,community direct support, customized in-home living supports, emergency response services,environmental mods, nutritional counseling, private duty nursing for adults, related goods,specialized therapies, transportation for aged individuals ages 65 – no max age and disabledindividuals ages 0 – 64.Provides case management, home health aide, respite, nutritional counseling, skilled therapyfor adults, behavior support consultation, private duty nursing, specialized medical equipmentand supplies for medically fragile individuals ages 0 – no max age.CMSCMSCMSCMSCMSCMSCMSCMSB-92014 Practitioner and Provider Manual - Ver. 3