New Mexico - Personal Assistance Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In New Mexico, Personal Assistance Services are primarily delivered under the Medicaid Centennial Care 1115 Waiver as the Agency-Based Community Benefit (ABCB) or Personal Care Services (PCS). These services provide essential hands-on assistance with activities of daily living (ADLs) such as bathing, dressing, transferring, and toileting, allowing participants to remain safely in their own homes rather than institutional settings.

The single biggest structural barrier to entry for a new provider in New Mexico is the mandatory requirement to secure network contracts with the state's Centennial Care Managed Care Organizations (MCOs). Even after obtaining state licensure and enrolling as a Medicaid Provider Type 363, a provider cannot receive referrals or bill for the vast majority of Medicaid personal care services without first passing the rigorous credentialing and contracting processes of these designated MCOs.

1. Service Definition and Scope

New Mexico defines Personal Care Services (PCS) as hands-on assistance and support provided to individuals who require help with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Under the Centennial Care program, this is formally administered as the Agency-Based Community Benefit (ABCB).

Services must be delivered in the participant's home or a community setting that complies with the federal HCBS Settings Final Rule, ensuring full integration and access to the community. All care is dictated by an Individualized Service Plan (ISP) developed by a care coordinator.

• Service Nomenclature: Personal Care Services (PCS) or Agency-Based Community Benefit (ABCB).
• Waiver Authorities: Centennial Care 1115 Waiver, Developmental Disabilities (DD) Waiver, and Mi Via Waiver.
• ADL Support: Hands-on assistance with bathing, dressing, grooming, eating, transferring, and toileting.
• IADL Support: Non-medical assistance with light housekeeping, meal preparation, laundry, and medication reminders.
• Setting Requirements: Services must be provided in the individual's own home or a presumed compliant community setting, strictly prohibiting institutional delivery.
• Care Limitations: Caregivers may not perform skilled nursing tasks, such as wound care or administering injections.

2. Regulatory and Oversight Agencies

Oversight of personal care providers in New Mexico is bifurcated between the agency that manages Medicaid funding and the agency that handles health facility licensing and quality assurance. The New Mexico Health Care Authority (HCA), formerly the Human Services Department (HSD), manages the Medicaid program and Centennial Care.

The New Mexico Department of Health (DOH) handles the physical licensing of agencies and conducts ongoing quality surveys. Providers must satisfy the requirements of both departments, as well as the specific Managed Care Organizations (MCOs) administering the benefits.

• Medicaid Authority: New Mexico Health Care Authority (HCA), Medical Assistance Division (MAD) (https://www.hca.nm.gov).
• Licensing Body: New Mexico Department of Health (DOH), Division of Health Improvement (DHI), Health Facility Licensing and Certification Bureau (https://www.nmhealth.org/about/dhi/hflc/).
• Waiver Program Management: DOH Developmental Disabilities Supports Division (DDSD) (https://www.nmhealth.org/about/ddsd/).
• Managed Care Oversight: Centennial Care MCOs, including Presbyterian Health Plan, Blue Cross Blue Shield of NM, and UnitedHealthcare (https://www.hca.nm.gov/medicaid/).
• Quality Assurance: DOH/DHI Quality Management Bureau (QMB) (https://www.nmhealth.org/about/dhi/qmb/).

3. Gatekeeping Prerequisites: Who Can Even Apply

New Mexico does not utilize a Certificate of Need (CON) program for personal care agencies, but it enforces strict programmatic and structural gates before an application is accepted. Providers cannot simply enroll in Medicaid; they must first obtain programmatic approval from the state and attest to federal compliance.

The most critical prerequisite is securing network inclusion with Centennial Care MCOs. Without MCO contracts, an agency has no mechanism to receive authorized participant allocations or bill for ABCB services.

• MCO Network Contracting: Mandatory prerequisite; providers must secure active contracts with Centennial Care MCOs to receive referrals and bill for ABCB services.
• Programmatic Approval: Applicants must obtain approval from the HCA/MAD Long-Term Services and Supports Bureau (LTSSB) prior to Medicaid enrollment.
• HCBS Settings Attestation: Providers must sign and submit the Centennial Care Agency-Based Community Benefit Provider Attestation Form confirming compliance with the Final Rule before HCA approval.
• Local Business Licensing: Providers must hold and submit active city or county business licenses for every region of operation prior to portal submission.
• NPI Requirement: The business entity must obtain an Organizational Type 2 National Provider Identifier (NPI) from the federal NPPES registry before applying.

4. Licensure and Certification Requirements

Agencies providing personal care in New Mexico must be licensed by the DOH Division of Health Improvement (DHI). Depending on the exact scope of services (e.g., if any skilled nursing is provided alongside personal care), the agency will apply for a Home Health Agency license or operate under specific non-agency/in-home care rules.

The application process requires the submission of comprehensive policy manuals that crosswalk directly to the New Mexico Administrative Code (NMAC). DHI conducts a readiness review and initial survey before granting the license.

• Licensing Authority: License issued by the DOH Division of Health Improvement (DHI) Licensing Department.
• Application Submission: Packets must be mailed to Department of Health - DHI/POB Licensing Dept, P.O. Box H, Santa Fe, NM 87504.
• Policy Crosswalk: Applicants must submit annotated policy and procedure manuals with a direct crosswalk to the applicable NMAC rules.
• Insurance Requirements: Proof of active general liability and professional liability insurance must be included with the application.
• Readiness Review: DHI evaluates provider readiness, including care protocols, staff qualifications, and safety measures, prior to approval.
• Life Safety Exemption: Life safety codes apply to most facility types, but home health and personal care agencies operating in participant homes are exempt from facility life safety inspections.

5. Medicaid Provider Enrollment

Once licensed and programmatically approved, agencies must enroll in the New Mexico Medicaid program via the state's MMIS portal, managed by Conduent. Providers enroll specifically to provide community benefits under the waiver.

Enrollment requires uploading all prerequisite approvals, licenses, and corporate documents. The state will verify the agency's credentials before issuing a Medicaid Provider ID, which is then used to finalize MCO credentialing.

• Provider Type: Agencies must enroll as an active Medicaid approved Provider Type 363 (Community Benefit Provider).
• Enrollment Portal: Applications are submitted through the New Mexico Medicaid Provider Enrollment Portal (https://nmmedicaid.portal.conduent.com/static/ProviderLogin.htm).
• Application Fee: Providers are subject to the federal Medicaid application fee (approximately $709) unless proof of payment to Medicare or another state Medicaid program is provided.
• Required Documents: Submissions must include Articles of Incorporation, IRS EIN confirmation, NPI confirmation, and the DOH license.
• Revalidation: Providers must revalidate their Medicaid enrollment every 3 to 5 years through the portal to maintain active billing status.

6. Staffing, Training and Background Checks

New Mexico enforces strict personnel standards to ensure the safety of vulnerable adults receiving HCBS. All caregivers, often referred to as Personal Care Attendants (PCAs), must clear state-mandated background checks before any client contact.

Agencies are responsible for providing and documenting comprehensive initial and ongoing training. Training must align with state-approved curricula covering basic health, safety, and ADL support.

• Age and Education: Caregivers must be at least 18 years of age and possess a high school diploma or GED.
• Background Checks: Mandatory fingerprint-based screening through the DOH Caregivers Criminal History Screening (CCHS) Program.
• Health Screening: Staff must pass a tuberculosis (TB) screening prior to providing direct care.
• Initial Training: Caregivers must complete 40 hours of initial training covering basic health, safety, and personal care tasks.
• Ongoing Training: Caregivers are required to complete an additional 10 hours of continuing education every year to maintain credentials.
• CNA Requirements: If utilizing Certified Nursing Assistants, they must complete 75 hours of training (59 classroom, 16 clinical).

7. Documentation, Policies and Records

Compliance in New Mexico requires meticulous record-keeping. Agencies must maintain detailed participant files, personnel records, and operational policies that are subject to audit by DHI/QMB and the MCOs.

A critical component of documentation is the use of Electronic Visit Verification (EVV) and strict adherence to the state's critical incident reporting timelines.

• Care Planning: Agencies must maintain an active, person-centered Individualized Service Plan (ISP) for every participant.
• Incident Reporting: Providers are required to report Critical Incidents to the state within 24 hours of knowledge of the occurrence.
• Policy Manuals: Must maintain comprehensive manuals covering clinical care, medication management, safety protocols, and personal care assistance.
• EVV Compliance: Agencies must utilize an Electronic Visit Verification (EVV) system to record the start and end times of all in-home personal care shifts.
• Personnel Files: Must retain documented proof of CCHS background clearance, TB test results, and training logs for all staff.
• Settings Compliance: Documentation must continuously demonstrate that the agency supports full access of individuals to the greater community.

8. Billing, Rates and Claims

Because New Mexico's Medicaid program is heavily managed care-driven, the vast majority of claims for personal care services are submitted directly to the Centennial Care MCOs rather than the state MMIS.

Claims must be supported by EVV data. Discrepancies between billed units and EVV records will result in automatic claim denials by the MCOs.

• Billing System: Claims are submitted to the participant's specific Centennial Care MCO (e.g., Presbyterian, BCBSNM) via their respective clearinghouses.
• Primary Code: Services are typically billed using HCPCS code T1019 (Personal care services, per 15 minutes).
• EVV Payer ID: Providers must use Payer ID 87726 specifically for electronic visit verification claims.
• Claim Identifiers: All claims must include the agency's NPI, Tax Identification Number (TIN), and the appropriate MCO Payer ID.
• Rate Structure: Reimbursement rates are established by HCA/MAD, though specific contract terms may be negotiated with the individual MCOs based on authorized budgets.

9. Approval Sequence and Timeline

Becoming a fully operational personal care provider in New Mexico is a sequential process that typically takes 6 to 9 months. Steps cannot be completed concurrently, as each phase requires the approval document from the previous phase.

Delays are most commonly experienced during the DOH licensing phase and the final MCO credentialing phase, both of which require extensive document review and committee approvals.

• Step 1: Business Registration & NPI: Register with the NM Secretary of State and obtain an IRS EIN and NPI (1-2 weeks).
• Step 2: DOH/DHI Licensing: Submit policy crosswalks and application to DHI for readiness review and licensure (60-90 days).
• Step 3: HCA/MAD Programmatic Approval: Submit the HCBS Settings Attestation and obtain LTSSB approval (30-60 days).
• Step 4: Medicaid Portal Enrollment: Submit the Provider Type 363 application through the Conduent portal (30-60 days).
• Step 5: MCO Credentialing: Apply for network inclusion and credentialing with Centennial Care MCOs (60-120 days).

10. Common Denials and Survey Findings

Applications and ongoing operations are frequently derailed by administrative oversights. The HCA/MAD Long-Term Services and Supports Bureau (LTSSB) has a strict policy of rejecting incomplete applications without review.

During DHI/QMB surveys, agencies are most often cited for personnel file deficiencies and failure to adhere to the strict timelines for critical incident reporting.

• Incomplete Applications: All incomplete applications submitted to the HCA/MAD LTSSB are rejected outright and not considered for review.
• Missing Local Licenses: Failure to maintain and submit active city/county business licenses to the YES.NM portal results in Medicaid termination.
• Background Check Lapses: Allowing caregivers to provide services before receiving official CCHS fingerprint clearance is a severe survey deficiency.
• EVV Non-Compliance: Failure to capture accurate EVV data or mismatching EVV records with billed claims leads to immediate financial denials.
• Settings Rule Violations: Failure to demonstrate community integration in the provider's operational policies or during annual site visits.
• Training Deficits: Missing documentation for the required 10 hours of annual continuing education for PCAs.

11. Key Contacts and Resources

Prospective providers must navigate multiple state portals and agency websites. The New Mexico Health Care Authority (HCA) and the Department of Health (DOH) provide the primary regulatory frameworks.

Providers should bookmark the Medicaid enrollment portal and the specific provider relations pages for the Centennial Care MCOs they intend to contract with.

• NM Health Care Authority (HCA): Oversees Medicaid and Centennial Care (https://www.hca.nm.gov).
• NM DOH Health Facility Licensing and Certification: Manages agency licensure (https://www.nmhealth.org/about/dhi/hflc/).
• NM Medicaid Provider Portal (Conduent): Portal for Type 363 enrollment (https://nmmedicaid.portal.conduent.com/static/ProviderLogin.htm).
• DOH Division of Health Improvement (DHI) Licensing Contact: Phone: (505) 476-9025.
• Centennial Care MCO Information: Guidelines for MCO contracting (https://www.hca.nm.gov/medicaid/centennial-care-for-providers/).
• DOH Developmental Disabilities Supports Division (DDSD): Manages waiver program specifics (https://www.nmhealth.org/about/ddsd/).

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