BCBSNM Will Implement a New Process for Member-Driven PCS Hour Decreases

Posted 10/16/23
Updated 10/31/23

Effective Nov. 7, 2023, Blue Cross and Blue Shield of New Mexico (BCBSNM) will implement a new process when a member requests a decrease in their current approved personal care service (PCS) hours.

There are situations where members are approved for a certain number of PCS hours per week but prefer to have a reduced number of hours on an ongoing basis. This can lead to recurring critical incident report (CIR) submissions for missed visits for providers when members don’t want to utilize all their approved time.

BCBSNM’s new process will help prevent this issue by having the member discuss with their care coordinator about a reduction in hours when they don’t want to use all their approved weekly PCS hours. The care coordinator will conduct a reassessment of approved PCS hours and meet with the member or their representative to determine if it’s appropriate to make a change in hours. The member will have to sign a new Community Benefit Member Agreement if it’s approved. This form will specify the reduced number of hours, any additional information about the reduction and BCBSNM will maintain a record of this agreement. 

Upon approval, the member will work with their PCS provider to revise their Individual Plan of Care (IPoC) to reflect their updated hours. BCBSNM will also update the PCS authorization in AuthentiCare to reflect the reduced hours.

Important Reminders

  • The request for reduction in PCS hours must be member-driven.
  • The request for reduction of hours should occur after at least 60 calendar days into the current approved authorization.
  • The reassessment of approved PCS hours can occur during the 60-day period.
  • The reduction in hours can’t be requested temporary or for a short time span.
  • The change in hours will be in place for the remainder of the member’s budget.
  • BCBSNM can deny the request if it’s determined reducing the member’s hours puts the member at risk.
  • The member can work with their care coordinator to increase their hours again if they experience a change in condition, natural supports or if another need arises.

Additional Information

If you have any questions, please reach out to your assigned network representatives, David Hall or Jessica Maito.

You can also call 877-232-5518 if you need assistance locating a member’s care coordinator.