Form MAD614 "Centennial Care Self-directed Community Benefit Employer of Record (Eor) Self-assessment" - New Mexico

What Is Form MAD614?

This is a legal form that was released by the New Mexico Human Services Department - a government authority operating within New Mexico. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 27, 2017;
  • The latest edition provided by the New Mexico Human Services Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MAD614 by clicking the link below or browse more documents and templates provided by the New Mexico Human Services Department.


Download Form MAD614 "Centennial Care Self-directed Community Benefit Employer of Record (Eor) Self-assessment" - New Mexico

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Centennial Care Self-Directed Community Benefit
Employer of Record (EOR) Self-Assessment
In order to be an employer of record (EOR) in the Centennial Care Self-Directed
Community Benefit (SDCB), a member must meet the following qualifications:
1. The member must not be a minor (under 18 years old);
2. The member must have the legal authority to enter into a contractual agreement with
his/her employees and vendors. The member must not have a plenary or limited
guardianship or conservatorship over financial matters in place;
3. If the member has a power of attorney (POA) that includes the authority to make
decisions regarding financial matters, the POA must be the member’s EOR due to the
financial responsibilities inherent in the SDCB program; and
4. The EOR cannot be a paid caregiver for any SDCB services.
Employer of Record (EOR) responsibilities include:
1. Keeping track of SDCB budget amounts spent on paying employees and for approved
services and related goods;
2. Arranging for the delivery of services, supports and goods as approved in the care plan;
3. Recruiting, hiring, training, managing, and firing your employees and other service
providers (service providers include employees, contractors and vendors);
4. Verifying and attesting that employees meet the minimum qualifications for employment
as required by the SDCB in the Centennial Care Policy Manual Section 9;
5. Establishing a mutually agreeable schedule for employees’ services in writing and
providing fair notice of changes in the employee’s work schedule in the event of
unforeseen circumstances or emergencies;
6. Authorizing and submitting all required documents to the Financial Management Agency
(FMA). Documents must be completed and provided to the FMA according to the
timelines and rules established by the State. Documents include, but are not limited to,
vendor and employee agreements, vendor information forms, criminal background check
forms, time-sheets, payment request forms (PRFs) and invoices, updated employee
information, and other documentation needed by the FMA to process payment to
employees and vendors;
7. Ensuring that employees do not begin work until all materials necessary for a criminal
background check have been received by the FMA and the employee has successfully
passed the Consolidated Online Registry (COR) Background Check;
8. Agreeing to select or employ the employee on an interim (temporary) basis until a final
criminal history record check has been completed, for those crimes determined to be
disqualifying convictions as stated in NMSA 1978, Section 29-17-3. The employer
discusses this with the employee and reserves the right to dismiss the employee based on
the results of the criminal history record check;
9. Providing fair notice of changes in the employee’s work schedule in the event of
unforeseen circumstances or emergencies;
MAD 614 Revised 3/27/17
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10. Authorizing completed employee timesheets and invoices in order to pay employees and
other providers according to the predetermined payroll schedule. Net wages will include
gross earnings calculated according to the employee’s pay rate, minus payroll deductions
for the employee’s share of applicable state, federal, and local payroll withholdings;
11. Reporting any incidents of abuse, neglect or exploitation by any employee or other
service provider to the support broker and/or MCO/care coordinator;
12. Maintaining employee and service records and documentation in accordance with SDCB
rules and Federal and State employment rules;
13. Fully cooperating with the NM Department of Workforce Solutions (DWS) in any
investigations or other matters related to his/her employees;
14. Fully cooperating with the State’s worker’s compensation carrier. Responsibilities
include reporting claims and providing information to the carrier;
15. Meeting Federal employer requirements, such as completing and maintaining a Federal I-
9 form for each employee as required by law; and
16. When necessary, requesting assistance from the care coordinator and/or support broker
with any of these responsibilities.
SDCB Advantages vs. Potential Risks
Advantages to the SDCB Model
 You have more control on who provides your services and when they are delivered.
 You will receive assistance from your care coordinator and support broker to help you be
a successful employer.
 You may choose someone else to be the (EOR) to perform the listed duties above.
Potential Risks to the SDCB Model
 You and your EOR are responsible for backup arrangements for services to be delivered
if your employee or service provider does not show up for work.
 Your employees and providers are not the employees of the FMA, The Human Services
Department, or any other state or federal agency.
 The EOR is responsible for meeting all requirements as any employer in any business and
can be held liable for failure to meet those requirements.
 Certain circumstances may result in your involuntary termination from the SDCB that will
result in a shift to ABCB; please refer to the SDCB involuntary termination policy in Section
8 of the Managed Care Policy Manual.
MAD 614 Revised 3/27/17
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Centennial Care Self-Directed Community Benefit
Employer of Record (EOR) Self-Assessment
This form is to be completed by the Self-Directed Community Benefit (SDCB) member and care
coordinator or support broker and submitted to the managed care organization (MCO) upon
annual care plan renewal or upon selecting the SDCB.
Member Name _______________________________________
Member Date of Birth______________________
Member ID#________________________
Managed Care Organization____________________________
Name of Care Coordinator and signature____________________________________________
Name of Support Broker and signature______________________________________________
Name of Support Broker Agency (if applicable)_______________________________________
To determine if the member can be his/her own EOR (use additional paper as necessary):
Is the member a minor? __________________ (If yes, the member cannot be his/her own EOR
and must select an EOR, do not answer the questions below.)
Does the member have a plenary guardianship or conservatorship in
place?_____________________ (If yes, the member cannot be his/her own EOR and must select
an EOR, do not answer the questions below)
Does the member have a power of attorney (POA) in place?________________________
(If yes, the MCO must obtain a copy of the POA and verify that it allows for the member to
legally enter into contractual relationships and perform all functions of an EOR). Please list the
name of the power of attorney and his/her relationship to the member
Additional questions:
Has the member received training on how to approve and submit timesheets electronically
through FOCOS?____________
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Does the member currently approve and submit timesheets electronically through
FOCOS?______________ If no, please explain why:
Do any of the member’s current employees or vendors have power of attorney for the member?
_______ If yes, please list the name(s) of the employees.
Does the member need assistance with any of the EOR responsibilities listed on pages 1&2 of
this form?
If yes, which ones?
Who will provide assistance?
Does the member understand the responsibilities of an EOR?___________________
Does the member want to be his/her own EOR? _________________ If no, who has the
member selected to be his/her EOR?(include relationship to the member)
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