Introduction 

New Mexico offers Medicaid Waiver programs to provide home and community-based services (HCBS) to individuals who require long-term care due to disabilities, age, or chronic health conditions. Becoming a licensed Medicaid Waiver provider in New Mexico allows you to offer critical services, such as personal care, respite care, and home health services, to these populations. This guide outlines the specific steps you need to take to become a licensed Medicaid Waiver provider in New Mexico. 

1. Understand New Mexico’s Medicaid Waiver Programs 

Description: New Mexico’s Medicaid Waiver programs support various populations, including individuals with developmental disabilities, the elderly, and those with chronic medical conditions. Providers must align their services with the state's specific waiver programs. 

Key Waiver Programs in New Mexico: 

Developmental Disabilities Waiver (DD Waiver): Provides comprehensive services for individuals with intellectual and developmental disabilities. 

Mi Via Waiver (Self-Directed Waiver): Allows individuals to self-direct their services and manage their own care budget. 

Medically Fragile Waiver: Serves individuals with developmental disabilities and medically fragile conditions. 

Community Benefits (1915(c) Waiver): Provides services to seniors and adults with disabilities to help them remain in their homes and communities. 

Key Steps: 

Determine the Waiver Program You Will Serve: Decide which waiver program aligns with your agency’s services and expertise. For example, if your focus is personal care for seniors, the Community Benefits waiver may be the best fit. 

Review Waiver Requirements: Visit the New Mexico Department of Health (NMDOH) or Human Services Department (HSD) websites to review specific program guidelines and provider qualifications for each waiver. 

Tips: Contact the Human Services Department: The New Mexico Human Services Department oversees Medicaid Waiver programs. You can contact them directly for program-specific questions and assistance in determining the best waiver for your services. 

2. Meet Provider Eligibility Requirements 

Description: To become a licensed provider, you must meet the eligibility criteria outlined by New Mexico Medicaid. These requirements ensure that providers can deliver quality care and comply with state and federal Medicaid regulations. 

Key Steps: 

Legal Business Registration: Register your agency as a legal business entity with the New Mexico Secretary of State. You may form an LLC, corporation, or sole proprietorship. Obtain an Employer Identification Number (EIN) from the IRS. 

Liability Insurance: Obtain the required general and professional liability insurance coverage. The state may specify minimum coverage amounts, which typically range between $1 million and $3 million. 

Staffing Requirements: Ensure that your agency employs appropriately trained and certified staff. Direct care staff must have the necessary certifications, such as: 

• CPR and First Aid certification. 

• Certified Nursing Assistant (CNA) certification (for personal care services). 

• Home Health Aide (HHA) certification (if applicable). 

• Licensed Registered Nurses (RN) or therapists for clinical services. 

Criminal Background Checks: Conduct state and federal criminal background checks for all direct care staff and administrative personnel. Fingerprinting may also be required. 

Tips: Review the specific qualifications for each type of provider or service you plan to offer. For example, certain waivers may require specialized training in developmental disabilities or behavioral health. 

3. Complete the Medicaid Waiver Provider Application 

Description: Once you meet the eligibility criteria, the next step is to complete the New Mexico Medicaid Waiver provider application. This process involves submitting detailed documentation about your agency, staff, and services. 

Key Steps: 

Obtain the Application: Download the provider application forms from the New Mexico Medicaid website, managed by the Human Services Department (HSD) or the Medical Assistance Division (MAD). The application may be specific to the waiver program you are applying for. 

Submit Required Documentation: The application process typically requires submitting: 

• Proof of business registration with the New Mexico Secretary of State. 

• Proof of liability insurance coverage. 

• Staff certifications, qualifications, and criminal background checks. 

• A completed IRS W-9 form. 

• Service delivery policies and procedures (e.g., care plans, client intake processes, incident reporting, grievance procedures). 

• Health and safety inspection reports (if operating a facility). 

Create Policies and Procedures: Develop comprehensive written policies and procedures that outline how your agency will comply with New Mexico Medicaid regulations. These should include: 

Client Assessment and Care Plans: A process for assessing clients’ needs and developing individualized care plans. 

Incident Reporting: Procedures for reporting critical incidents, such as abuse, injury, or neglect. 

Staff Training and Supervision: Policies for ongoing staff training and compliance with state certification requirements. 

Client Rights and Grievances: Processes to ensure clients’ rights are protected and that they can file grievances if necessary. 

Submit the Application: Once you have completed the application and gathered all supporting documentation, submit it to the New Mexico Medicaid office. Applications may be submitted electronically or by mail, depending on the program. 

Tips: Review the application checklist carefully to ensure you have included all required documentation. Incomplete applications can delay the approval process. 

4. Prepare for Background Checks and Staff Screening 

Description: Before your application can be fully processed, the state will conduct background checks on your agency’s staff to ensure they meet eligibility requirements for working with vulnerable populations. 

Key Steps: 

Complete Background Checks: Submit all necessary criminal background check documentation for direct care workers, administrators, and licensed staff. Background checks will typically include both state and federal records, as well as registry checks for child abuse and elder abuse. 

Fingerprinting: Some staff may be required to undergo fingerprinting as part of the background check process. Check with your specific waiver program to see if this applies. 

Ensure Compliance with Staff Requirements: Verify that all staff meet New Mexico’s staffing requirements, including certifications, licenses, and ongoing training requirements. 

Tips: Start background checks and fingerprinting early, as processing times can vary. Many third-party providers offer background check services approved by New Mexico. 

5. Prepare for Site Visits and Inspections (If Required) 

Description: If your Medicaid Waiver services involve operating a physical facility (e.g., a group home or adult day center), New Mexico may require an on-site inspection before granting your provider license. 

Key Steps: 

Schedule a Pre-Inspection: Contact the appropriate state agency to schedule a pre-inspection of your facility, if required. Inspections will focus on ensuring compliance with health and safety regulations. 

Prepare Your Facility: Ensure that your facility meets all state safety and health standards. Common inspection criteria include: 

• Compliance with fire safety regulations (fire exits, smoke detectors, etc.). 

• Accessibility for individuals with disabilities (e.g., ramps, ADA-compliant bathrooms). 

• Proper storage and handling of medications (if applicable). 

• Cleanliness and maintenance of living spaces, kitchens, and bathrooms. 

Have Documentation Ready: During the site visit, inspectors may request to see policies and procedures, staff training logs, and client care plans. Ensure these documents are easily accessible. 

Tips: Use a facility readiness checklist to ensure compliance with state health and safety codes before your inspection. 

6. Receive Approval and Provider Certification 

Description: Once your application and inspections (if required) are complete, you will receive your official approval as a Medicaid Waiver provider in New Mexico. 

Key Steps: 

Receive Your Medicaid Provider Identification Number (PID): Once approved, you will receive your Medicaid Provider Identification Number (PID) or National Provider Identifier (NPI). This number allows you to bill Medicaid for services. 

Complete Training (If Required): Some waiver programs may require you to attend orientation or training sessions after approval. These sessions will cover compliance, service delivery standards, and Medicaid billing procedures. 

Enroll in Medicaid Billing: Register with the state’s Medicaid billing system to submit claims electronically for services provided. New Mexico uses the Provider Enrollment Unit (PEU) and Conduent systems for billing. 

Tips: Keep your Medicaid Provider Identification Number in a secure location, as it will be required for billing and future audits.