Consistent with Letter of Direction (LOD) #108 from the New Mexico Human Services Department, effective Feb. 1, 2024, Blue Cross and Blue Shield of New Mexico has implemented a new process for personal care agencies that need to hire a legal responsible individual (LRI) to serve as a caregiver.
The LOD provided expanded authority to hire an LRI as a paid caregiver for members under extraordinary circumstances, which include the inability to find and retain other qualified, suitable caregivers when the parent/guardian/spouse (LRI) would absent from the home and, thus, the LRI must stay at home to ensure the member’s health and safety and to avoid institutionalization.
The LOD defines an LRI as “a person who has a duty under State law to care for another person.” This typically includes: “the parent (biological or adoptive) of a minor child; the guardian of a minor child who must provide care to the child; or the spouse of a member.”
Agency Based Community Benefit (ABCB) and Early Periodic Screening, Diagnostic and Treatment (EPSDT)
The request to employ an LRI as a caregiver to provide Personal Care Services (PCS) must be made by the PCS agency with the member’s and or their legal guardian input and permission. After consultation with member and their care coordinator, if determined an LRI is needed to provide the services, the PCS agency will submit required paperwork to the BCBSNM Utilization Management (UM) team for requested approval.
Self-Directed Community Benefit (SDCB)
SDCB members requesting PCS services be provided by a LRI will need to work with their care coordinator, support broker (SB) and employer of record. If determined an LRI is needed to provide the services, the SB will submit required paperwork to the UM team for requested approval.
Process
PCS Agencies or Support Brokers must submit the Request for Services by a Legally Responsible Individual Form (the REQUEST).
The REQUEST must include documentation showing all attempts to employ other available resources in the members community, the challenges the member and/or providers encountered, and why non-LRI providers were unable to successfully provide the approved covered service.
The REQUEST can be emailed to pcs@bcbsnm.com or faxed to 505-816-3854.
The UM team will review the REQUEST and determine if a LRI is approved within seven business days of receiving the REQUEST.
- BCBSNM will return the REQUEST to the PCS agency, or the SB notated with approval if the REQUEST is accepted.
- The member and PCS agency will receive a denial letter if BCBSNM doesn’t approve the request and the PCS agency, or the SB will receive a call from the UM team within 24 hours of the denial determination.
If further documentation is needed, the UM team will make two outreach attempts during the seven-business day period. If the required documentation is not received timely, the request may be denied by the MCO medical director.
Additional Requirements
- BCBSNM approval must be received before the LRI begins to provide services.
- LRIs require approval by BCBSNM on an annual basis.
- LRIs must meet the same requirements as other caregivers including employment qualifications and training standards.
- Services provided by LRIs must meet the definition of a covered service and be specified in the member’s approved care plan.
Additional Information
For more information or to view the full LOD, please visit HSD’s website.