Developmental Disabilities Waiver (DD), CoLTS c Waiver (formerly known as Disabled & Elderly [D&E] Waiver), Medically Fragile Waiver, and AIDS Waiver

Medicaid Home and Community-Based Services are provided under separate 1915 (c) waivers through the federal Centers for Medicare and Medicaid Services to allow state Medicaid agencies to cover home and community-based services for individuals that require long-term supports and services in order to enable recipients to reside in the community rather than in institutions.

CoLTS c Waiver recipients with a new allocation that are not enrolled with a CoLTS managed care organization (MCO), either AMERIGROUP Community Care or Evercare of New Mexico, will work with Molina Healthcare TPA to ensure all required documentation is submitted.

Level of Care:
Annual Reviews - Medically Fragile, AIDS, DD, and CoLTS c Waivers.

Forms for Level of Care:
Medically Fragile Waiver: Use form DOH 378; this waiver is based on meeting the medically fragile criteria.

 DOH 378

AIDS and CoLTS c Waiver: Use form MAD 379; review is based on meeting the nursing facility criteria.

 MAD 379

DD Waiver: Use form MAD 378; criteria for meeting this level of care are based on the ICF-MR criteria.

 Mad 378

CoLTS c Waiver Expedited Emergency Allocations:
Requests for expedited emergency allocations for the CoLTS c Waiver are processed by the Aging and Long-Term Services Department(ALTSD). The ALTSD will then forward these requests for utilization review by Molina Healthcare TPA to determine if they meet the criteria necessary for expedited emergency allocation.

Individual Service Plans:

AIDS, Developmental Disability, and Medically Fragile waiver recipients work with his or her Waiver case manager to develop the individual service plan (ISP). Molina Healthcare TPA is responsible for entering these prior approved ISPs into the Omnicaid system. A prior authorization (PA) number will be sent to the case management agency. (Note: Please see the information below regarding ISP development for CoLTS c Waiver (CCW) recipients).

All ISPs are submitted to Molina Healthcare TPA on form MAD 046 with appropriate HIPAA-compliant codes.

·         AIDS/ARC Waiver: ISPs received by Molina Healthcare TPA are entered into Omnicaid and an authorization (PA) number will be sent to the case management agency.

·         CoLTS c Waiver: CCW recipients will work with the CoLTS MCO to develop the ISP for personal care hours. For recipients not yet enrolled in CoLTS, Molina Healthcare TPA will work with the recipient to develop an ISP for personal care hours. 

·         DD Waiver: Molina Healthcare TPA is responsible for reviewing outlier services, awake staffing, and changes to residential status. These services are measured against the Service Standards and the documentation provided.

·         Medically Fragile Waiver: ISPs received by Molina Healthcare TPA are entered into Omnicaid and an authorization (PA) number will be sent to the case management agency.

 Mad 046 

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