1915(c) Waiver Allocation and Transition Guide
NEW ALLOCATONS to Developmental Disabilities Waiver (DDW), Mi Via, or Supports Waiver
Steps: New
Allocations
Case Manager (CM), Consultant, Community Supports Coordinator (CSC)
Responsibility
Additional Requirements for
Self-Directed Programs
Step 1
Receipt of PFOC
Upon receipt of the PFOC and before initial contact, review the Medicaid web portal
to determine if there is an existing Category of Eligibility (COE) for the allocation
1. The COE – there are multiple COEs that offer full Medicaid benefits including,
but not limited to:
001, 003, 004 – SSI Categories
100, 200, 300, 400 – MAGI Medicaid Categories
081, 083, 084 – Institutional Care
090, 091, 092, 093, 094 – Long-Term Care Categories
037, 046, 066 – Children Youth and Family (CYFD) Categories
095 – Medically Fragile Waiver (MFW)
Full coverage categories, not listed in this document, may be less common. If
an agency has a question about a COE please contact the Consolidated
Consumer Services Center (CCSC).
2. If there is a COE verify the Level of Care (LOC) and Setting of Care (SOC):
Presence of a Level of Care and Setting of Care indicate the individual receives
long-term care services through another program and services must be
coordinated to ensure continuity of care.
Program
LOC
SOC
Community Benefit – Agency
Directed Waiver
NFL
ABD
Community Benefit – Agency
Directed No Waiver
NFL
ANW
1915(c) Waiver Allocation and Transition Guide
Community Benefit – Self-
Directed
NFL
SDB
Community Benefit – Self
Directed Non-Waiver
NFL
SNW
Nursing Facility
NFL
INF
ICF/IID
MR1, MR2, or MR3
(Not Required)
Mi Via * Medically Fragile
MRO
MIV
Mi Via
MRO
MIV
Supports Waiver Agency Based
MRO
SWA
Supports Waiver Participant
Directed
MRO
SWD
*MFW will not have a LOC/SOC and can be identified by the COE 095. A Mi
Via recipient who is medically fragile (COE095) can be identified by the COE
095 and LOC/SOC of MRO/MIV.
3. Managed Care Organization
If the individual does not have an existing Medicaid category that requires
transition of care, then proceed to Step 4.
Step 2
Coordination
with Other
Programs
The CM/Consultant/CSC is required to coordinate a transition meeting.
For individuals receiving long-term care services through an MCO, as indicated by
the LOC/SOC, contact the MCO Care Coordinator to schedule a transition meeting.
For individuals receiving services through an Intermediate Care Facility for
Individuals with Intellectual Disabilities (ICF/IID) contact the ICF/IID provider to
schedule a transition meeting.
For individuals receiving services though the Medically Fragile Waiver (MFW)
contact the UNM Medically Fragile Case Management Program (MFCMP) to schedule
a transition meeting.
The receiving agency will follow the applicable regional office request for assistance
(RORA) process if they are unable to reach the discharging agency.
1915(c) Waiver Allocation and Transition Guide
Step 3
Transition
Meeting
The transition meeting must include the individual and/or the individual’s legal
representative as well as either the MCO Care Coordinator, ICF/IID provider, or MFW
Nurse Case Manager.
During the meeting a transition date must be established. The transition date is the
date when the budget under the existing program ends and the new waiver budget
begins. The transition date must be agreed upon by all parties. The start date for the
budget, Individual Service Plan (ISP) or Service and Support Plan (SSP) must allow
enough time to coordinate transition of services such that:
1. There is no gap in service and continuity of care is maintained;
2. The individual fully transitions out of existing service and the rendering
provider is informed of the service end date.
If there are changes to the agreed upon transition date after the meeting occurred,
it is the responsibility of the receiving agency to inform all parties who participated
in the transition meeting of the changes. It is the receiving agency’s responsibility
to keep all parties informed of transitioned updates throughout the process to
ensure there are no gaps in service.
Step 4
Income Support
Division
Application
Client submits a completed application (HSD 100) to the Income Support Division
(ISD) Institutional Care (IC) and Waiver Unit for determination of eligibility to establish
the waiver COE 096. An application may be submitted in the following ways:
Online – www.yes.state.nm.us
Fax – 1-855-804-8960
Phone – 1-855-637-6574
Or by mail – Central ASPEN Scanning Area (CASA)
PO BOX 830
Bernalillo, NM 87004
ISD determines financial and medical eligibility based upon the information provided.
The LOC is required for eligibility and will be provided to ISD by the Third-Party
Assessor (TPA) via an interface. If an individual has not received a Social Security
1915(c) Waiver Allocation and Transition Guide
determination of disability ISD will request a Disability Determination Unit (DDU)
review as part of the medical eligibility requirement.
* An application (HSD 100) to ISD will not be required if the customer has an active
Institutional Care (IC) or waiver category. The Primary Freedom of Choice (PFOC) will need to
be provided to the IC/Waiver unit to change COE. Other full coverage Medicaid will still need
an application.
Step 5
Level of Care
Process
Submit the LOC packet to the TPA, Comagine Health (formerly known as Qualis
Health,) using the JIVA provider portal for a LOC determination.
Normal Submission Process
(Match Letter Not Required)
• MAD 378 signed by Physician, PA, or CNP
• Current H & P
• Current CIA
• MAD 378 signed by Physician, PA or CNP
• Current H &P
• Current IHA
• MAD 378 signed by Physician, PA or CNP
• Current H & P
Once the TPA completes their review, the TPA will send the LOC determination to the
ISD office so that ISD can establish and complete the waiver eligibility.
Note: If ISD has not received a Level of Care from the TPA and the
CM/Consultant/CSC has verified in JIVA that the LOC review has been completed,
please contact the appropriate MAD/ESPB program staff for assistance.
Individuals on Mi Via may fax
their LOC packet to 1-800-251-
9993.
1915(c) Waiver Allocation and Transition Guide
Step 6
Service Plan and
Budget
Development
The CM/Consultant/CSC should begin working with the individual to begin the
person-centered planning process and to develop the ISP or SSP and budget. This
step may happen simultaneously with steps 4 & 5.
The ISP or SSP and the budget may not have an effective date prior to the begin date
of the COE 096. The Consultant/CSC may submit the ISP or SSP and budget for review
but the TPA may not approve or complete Omnicaid entry until the COE 096 is active.
If the submitted ISP or SSP and budget have a begin date prior to the COE effective
date the TPA will create an RFI.
Note: ISP or SSP and budgets for
Mi Via and SW must begin on the
1
st
day of the month.
Step 7
Monitoring
Timeline
Monitor steps 4-6 for timeliness and follow up regularly to verify if:
• The LOC is pending;
• The COE is pending; or
• Both the LOC and COE are pending; and
Based on what information is found follow up, as appropriate, to facilitate processing
of the LOC, COE and/or both.
Notify all parties who participated in the transition meeting of any changes to the
transition timeline and update and submit the CIU as required. If there are concerns
that a gap in service could occur, the agency will immediately contact applicable
DDSD staff for review.
DDW- Statewide CM Coordinator or RO CM Coordinator
SW- Program Staff
MFW – Program Manager
Step 8
Service Plan &
Budget
Submission
After the CM/Consultant/CSC verifies the COE 096 is approved, submit the ISP or SSP
and budget process following program guidelines assuring that there are no gaps in
services.
Note: If the anticipated budget start date has changed, the CM/Consultant/CSC will
contact the members of the transition meeting as quickly as possible to coordinate
provision of services as a result of the change. If there are concerns that a gap in
service could occur, the agency will immediately contact applicable DDSD staff for
review.
Note: ISP or SSP and budgets for
Mi Via and SW must begin on the
1
st
day of the month.
The budget must be submitted
before the 14
th
day of the
current month in order to begin
the 1
st
day of the following
month. Example: The budget is
1915(c) Waiver Allocation and Transition Guide
DDW- Statewide CM Coordinator or RO CM Coordinator
SW- Program Staff
MFW – Program Manager
submitted on 1/10, the budget
start date would be 2/1 or after.
If the budget is submitted on, or
after the 15
th
, day of the month
then the budget start date would
be the 1
st
day of the following
month. Example: The budget is
submitted on 1/15 the start date
would be 3/1 or after.
Step 8
Verification of
Services
The CM/Consultant/CSC and agency-based waiver providers MUST check the
Medicaid web portal to verify begin date of waiver COE 096 and an approved waiver
budget BEFORE providing services.
Self-directed providers including
employees and vendors are not
able to verify eligibility
information in the Medicaid
Portal and rely on the
Consultant/CSC and EOR to
notify the provider that services
may begin.
Step 9
Notification to
ISD
After the CM/Consultant/CSC verifies that an ISP or SSP and budget have been
approved for the individual and the individual is in service, the agency will send a CIU
via fax to ISD notifying them of the approved budget start date.
ISD will then close coexisting COEs as appropriate.
The receiving agency will submit a copy of the CIU to the DDSD Regional Office.
Note: A CIU does not need to be submitted to ISD if the individual did not have a
Medicaid COE prior to the waiver.