New Mexico Register / Volume XXIX, Issue 24 /
December 27, 2018
TITLE 8 SOCIAL SERVICES
CHAPTER
200 MEDICAID ELIGIBILITY - GENERAL
RECIPIENT RULES
PART 400 GENERAL MEDICAID ELIGIBILITY
8.200.400.1 ISSUING AGENCY: New
Mexico Human Services Department (HSD).
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8.200.400.2 SCOPE: The
rule applies to the general public.
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8.200.400.3 STATUTORY AUTHORITY: The
New Mexico medicaid program and other health care programs are administered
pursuant to regulations promulgated by the federal department of health and
human services under Title XIX of the Social Security Act as amended or by
state statute. See Section 27-1-12 et
seq., NMSA 1978.
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8.200.400.4 DURATION:
Permanent.
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8.200.400.5 EFFECTIVE DATE: January 1, 2019, or upon a later approval date by the federal centers
for medicare and medicaid services (CMS), unless a later date is cited at the
end of the section.
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8.200.400.6 OBJECTIVE: The
objective of this rule is to provide specific instructions when determining
eligibility for the medicaid program and other health care programs. Generally, applicable eligibility rules are
detailed in the medical assistance division (MAD) eligibility policy manual,
specifically 8.200.400 NMAC, General
Medicaid Eligibility. Processes for
establishing and maintaining MAD eligibility are detailed in the income support
division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs.
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8.200.400.7 DEFINITIONS: [RESERVED]
8.200.400.8 [RESERVED]
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8.200.400.9 GENERAL
MEDICAID ELIGIBILITY: Medicaid
services are jointly financed by the federal government and the state of New
Mexico and are administered by medical assistance division (MAD).
A. Within broad
federal regulations, New Mexico determines categories of eligible recipients,
eligibility requirements, types and range of services, levels of provider
reimbursement and managed care capitation, and administrative and operating
procedures.
B. New
Mexico administers medical assistance programs using waivers of the Social
Security Act for comparability of services, rules for income and resources and
freedom of choice of provider.
C. Payments for
medical and behavioral health services, durable equipment and supplies are made
directly to service providers, not to the medicaid eligible recipient.
D. This chapter
describes the New Mexico categories of medicaid and medical assistance programs
eligibility. Each medicaid and medical
assistance program includes detailed eligibility requirements which are
organized into the following three chapter types:
(1) recipient requirements (.400);
(2) income and resources standards (.500); and
(3) benefit description (.600).
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8.200.400.10 BASIS FOR DEFINING GROUP - MEDICAID
CATEGORIES:
A. Except where noted,
the HSD income support division (ISD) determines eligibility in the categories
listed below:
(1) other adult (Category 100);
(2) parent caretaker (Category 200);
(3) pregnant women (Category 300);
(4) pregnancy-related
services (Category 301);
(5) loss of parent caretaker due to earnings from employment or
due to spousal support (Categories 027 and 028);
(6) newborn (Category 031);
(7) children under age 19 (Categories 400, 401, 402, 403, 420,
and 421);
(8) children, youth, and families department medicaid
(Categories 017, 037, 046, 04, 066, and 086); and
(9) family planning (Category 029).
B. Medicare savings program (MSP): MSP assists an eligible recipient with the
cost of medicare.
(1) Medicare
is the federal government program that provides health care coverage for
individuals 65 or older; or under 65 who have a disability. Individuals under 65 who have a disability are
subject to a waiting period of 24 months from the approval date of social
security disability insurance (SSDI) benefits before they receive medicare
coverage. Coverage under medicare is
provided in four parts.
(a) Part
A hospital coverage is usually free to beneficiaries when medicare taxes are
paid while working.
(b) Part
B medical coverage requires monthly premiums, co-insurance and deductibles to
be paid by the beneficiary.
(c) Part
C advantage plan allows a beneficiary to choose to receive all medicare health
care services through a managed care organization.
(d) Part
D provides prescription drug coverage.
(2) The
following MSP programs can assist an eligible recipient with the cost of
medicare.
(a) Qualified medicare beneficiaries
(QMB) - Categories 041 and 044: QMB covers low income medicare beneficiaries
who have or are conditionally eligible for medicare Part A. QMB benefits are limited to the following:
(i) cost for the monthly medicare Part B premium;
(ii) cost of medicare deductibles and coinsurance; and
(iii) cost for the monthly medicare Part A
premium (for those enrolling conditionally).
(b) Specified
low-income medicare beneficiaries (SLIMB) - Category 045: SLIMB medicaid covers low-income medicare
beneficiaries who have medicare Part A.
SLIMB is limited to the payment of the medicare Part B premium.
(c) Qualified individuals 1 (QI1s) - Category
042: QI1 medicaid covers low-income
medicare beneficiaries who have medicare Part A. QI1 is limited to the payment of the medicare
part B premium.
(d) Qualified
disabled working individuals (QDI) - Category 050: QDI medicaid covers low
income individuals who lose entitlement to free medicare Part A hospital
coverage due to gainful employment. QDI
is limited to the payment of the monthly Part A hospital premium.
(e) Medicare
Part D prescription drug coverage - low income subsidy (LIS) - Category 048: LIS provides individuals enrolled in
medicare Part D with a subsidy that helps pay for the cost of Part D
prescription premiums, deductibles and co-payments. An eligible recipient receiving medicaid
through QMB, SLMB or QI1 is automatically deemed eligible for LIS and need not
apply. Other low-income medicare
beneficiaries must meet an income and resource test and submit an application
to determine if they qualify for LIS.
C. Supplemental
security income (SSI) related medicaid:
(1) SSI - Categories 001, 003 and 004:
Medicaid for individuals who are eligible for
SSI. Eligibility for SSI is determined
by the social security administration (SSA).
This program provides cash assistance and medicaid for an eligible
recipient who is:
(a) aged (Category 001);
(b) blind (Category 003); or
(c) disabled (Category 004).
(2) SSI medicaid
extension - Categories 001, 003 and 004: MAD provides coverage for certain groups of
applicants or eligible recipients who have received supplemental security
income (SSI) benefits and who have lost the SSI benefits for specified reasons
listed below and pursuant to 8.201.400 NMAC:
(a) the pickle amendment and 503 lead;
(b) early widow(er);
(c) disabled widow(er) and a disabled surviving divorced spouse;
(d) child insurance benefits, including disabled adult children
(DAC);
(e) nonpayment SSI status (E01);
(f) revolving SSI payment status “ping-pongs”; and
(g) certain
individuals who become ineligible for SSI cash benefits and, therefore, may
receive up to two months of extended medicaid benefits while they apply for
another MAD category of eligibility.
(3) Working disabled individuals (WDI)
and medicare wait period - Category 074:
There are two eligibility
types:
(a) a disabled individual who is employed; or
(b) a disabled individual who has lost SSI medicaid due to
receipt of SSDI and the individual does not yet qualify for medicare.
D. Long term care medicaid:
(1) medicaid for individuals who meet a nursing facility (NF)
level of care (LOC), intermediate care facilities for the intellectually
disabled (ICF-ID) LOC, or acute care in a hospital. SSI income methodology is
used to determine eligibility. An
eligible recipient must meet the SSA definition of aged (Category 081); blind
(Category 083); or disabled (Category 084).
(2) Institutional care (IC) medicaid -
Categories 081, 083 and 084: IC covers certain inpatient, comprehensive
and institutional and nursing facility benefits.
(3) Program
of all-inclusive care for the elderly (PACE) - Categories 081, 083 and 084:
PACE uses an
interdisciplinary team of health professionals to provide dual
medicaid/medicare enrollees with coordinated care in a community setting. The PACE program is a unique three-way
partnership between the federal government, the state, and the PACE
organization. The PACE program is
limited to specific geographic service area(s).
Eligibility may be subject to a wait list for the following:
(a) the aged (Category 081);
(b) the blind (Category 083); or
(c) the disabled (Category 084).
(4) Home
and community-based 1915 (c) waiver services (HCBS) - Categories 090, 091, 092,
093, 094, 095 and 096: A 1915(c)
waiver allows for the provision of long term care services in home and
community based settings. These programs
serve a variety of targeted populations, such as people with mental illnesses,
intellectual disabilities, or physical disabilities. Eligibility may be subject to a wait list.
(a) There are two HCBS delivery models:
(i) traditional agency delivery where HCBS are delivered and
managed by a MAD enrolled agency; or
(ii) mi
via self-directed where an eligible recipient, or his or her representative,
has decision-making authority over certain services and takes direct
responsibility to manage the eligible mi via recipient’s services with the
assistance of a system of available supports; self-direction of services allows
an eligible mi via recipient to have the responsibility for managing all
aspects of service delivery in a person-centered planning process.
(b) HCBS waiver programs include:
(i) elderly (Category 091), blind (Category 093) and disabled
(Category 094);
(ii) medically fragile (Category 095);
(iii) developmental disabilities (Category 096); and
(iv) self-directed model for Categories 090, 091, 093, 094, 095,
096 and 092).
E. Emergency
medical services for aliens (EMSA):
EMSA medicaid covers certain noncitizens who either are undocumented or
who do not meet the qualifying non-citizen criteria specified in 8.200.410 NMAC. Non-citizens must meet all eligibility
criteria for one of the medicaid categories noted in 8.285.400 NMAC, except for
citizenship or qualified non-citizen status. Medicaid eligibility for and coverage of
services under EMSA are limited to the payment of emergency services from a
medicaid provider.
F. Refugee medical assistance (RMA) - Categories 049 and 059: RMA
offers health coverage to certain low income refugees during the first eight
months from their date of entry to the United States (U.S.) when they do not
qualify for other medicaid categories of eligibility. A RMA eligible refugee recipient has access
to a benefit package that parallels the full coverage medicaid benefit package. RMA is funded through a grant under Title IV
of the Immigration and Nationality Act (INA).
A RMA applicant who exceeds the RMA income standards may “spend-down”
below the RMA income standards for Category 059 by subtracting incurred medical
expenses after arrival into the U.S.
G. Breast and
cervical cancer (BCC) - Category 052: BCC medicaid provides
coverage to an eligible uninsured woman, under the age of 65 who has been
screened and diagnosed by the department of health (DOH) as having breast or
cervical cancer to include pre-cancerous conditions. The screening criteria are set forth in the
centers for disease control and prevention’s national breast and cervical
cancer early detection program (NBCCEDP).
Eligibility is determined using DOH notification and without a separate
medicaid application or determination of eligibility.
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8.200.400.11 PRESUMPTIVE ELIGIBILITY FOR BREAST AND
CERVICAL CANCER: PE provides immediate access to health
services when an individual appears to be eligible for Category 052.
A. Breast and cervical cancer (BCC) (Category 052): PE
provides temporary medicaid coverage for an uninsured woman, under the age of
65 who has been screened and diagnosed by the DOH as having breast or cervical
cancer to include pre-cancerous conditions.
Only one PE period is allowed per calendar year.
B. PE is determined
by a qualified entity certified by HSD.
Qualified entities may include community and rural health centers,
hospitals, physician offices, local health departments, family planning agencies
and schools.
C. The PE period
begins on the date the provider determines presumptive eligibility and
terminates at the end of the following month.
D. Providers shall notify
the MAD claims processing contractor of the determination within 24-hours of the
PE determination.
E. For continued
medicaid eligibility beyond the PE period, a completed and signed application
for medicaid must be submitted to HSD/ISD.
An eligible PE provider must submit the application to ISD within 10
calendar days from the receipt of the application.
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8.200.400.12 12 MONTHS CONTINUOUS
ELIGIBILITY FOR CHILDREN (42 CFR 435.926):
A. HSD
provides continuous eligibility for the period specified in Subsection B of 8.200.400.14
NMAC for an individual who is:
(1) Under
age 19 and
(2) Eligible
and enrolled for mandatory or optional coverage under the State plan.
B. The continuous eligibility period is 12
months. The continuous eligibility
period begins on the effective date of the individual's eligibility or most
recent redetermination or renewal of eligibility.
C. A child's
eligibility may not be terminated during a continuous eligibility period,
regardless of any changes in circumstances, unless:
(1) The
child attains the maximum age of 19;
(2) The
child or child's representative requests a voluntary termination of
eligibility;
(3) The
child ceases to be a resident of New Mexico;
(4) The
agency determines that eligibility was erroneously granted at the most recent determination,
redetermination or renewal of eligibility because of agency error or fraud,
abuse, or perjury attributed to the child or the child's representative; or
(5) The
child dies.
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8.200.400.13 AUTHORIZED REPRESENTATIVE: HSD must permit applicants and beneficiaries to designate an individual or organization to act responsibly on their behalf in assisting with the individual’s application and renewal of eligibility and other ongoing communications.
A. Such a designation must be in writing including the applicant’s signature, and must be permitted at the time of application and at other times. Legal documentation of authority to act on behalf of an applicant or beneficiary under state law, such as a court order establishing legal guardianship or a power of attorney, shall serve in the place of written authorization by the applicant or beneficiary.
B. Representatives may be authorized to:
(1) sign an application on the applicant’s behalf;
(2) complete and submit a renewal form;
(3) receive copies of the applicant or beneficiary’s notices and other communications from the agency; and
(4) act on behalf of the applicant or beneficiary in all other matters with the agency.
C. The power to act as an authorized representative is valid until the applicant or beneficiary modifies the authorization or notifies the agency that the representative is no longer authorized to act on his or her behalf, or the authorized representative informs the agency that he or she is no longer acting in such capacity, or there is a change in the legal authority upon which the individual’s or organization’s authority was based. Such notice must be in writing and should include the applicant or authorized representative’s signature as appropriate.
D. The authorized representative is responsible for fulfilling all responsibilities encompassed within the scope of the authorized representation to the same extent as the individual he or she represents, and must agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or beneficiary provided by the agency.
E. As a condition of serving as an authorized representative, a provider, staff member or volunteer of an organization must sign an agreement that he or she will adhere to the regulations relating to confidentiality (relating to the prohibition against reassignment of provider claims as appropriate for a health facility or an organization acting on the facility’s behalf), as well as other relevant state and federal laws concerning conflicts of interest and confidentiality of information (42 CFR 435.923).
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8.200.400.14 RETROACTIVE MEDICAID:
A. HSD must make
eligibility for medicaid effective no later than the first or up to the third
month before the month of application if the individual:
(1) Requested
coverage for months prior to the application month;
(2) received medicaid services, at any time during that period,
of a type covered under the plan and;
(3) would have been eligible for medicaid at the time he or she
received the services, if he or she had applied (or an authorized
representative has applied for him or her) regardless of whether the individual
is alive when application for medicaid is made.
B. Eligibility for
medicaid is effective on the first day of the month if an individual was
eligible at any time during that month.
C. Eligibility for
each retroactive month is determined separately. Retroactive medicaid must be requested within
180 days of the date of the medicaid application.
D. Retroactive
eligibility is limited to one month for most centennial care managed care
members, as described in Subsection E of 8.200.400.14 NMAC. Retroactive eligibility is allowed for up to
three months for individuals and categories as described in Subsection F of
8.200.400.14 NMAC. All retroactive
periods are limited to one month prior to the application month when the
individual or category would be enrolled into managed care for the application
month or month prior.
E. Centennial care
managed care members on one of the following medicaid categories of eligibility
(COEs) during the month of application or month prior are limited to
retroactive medicaid for one month prior to the application month for these
categories:
(1) other adults (COE 100) with a federal poverty level (FPL)
less than or equal to one hundred percent;
(2) other adults (COE 100) with an FPL greater than one hundred
percent who applied prior to July 1, 2019;
(3) parent caretaker (COE 200);
(4) supplemental security income (SSI COEs 001, 003, and 004);
(5) SSI
extensions (COEs 001, 003, and 004, e.g. 503s, disabled adult children, ping
pongs, and early widower);
(6) working disabled individuals (WDI COE 074); and
(7) breast and cervical cancer (BCC COE 052)
(8) an incarcerated individual suspended from centennial care
enrollment for the application month is limited to one month of retroactive
medicaid for the month prior to the application month for the medicaid categories
listed in Subsection E of 8.200.400.14 NMAC.
F. The following
individuals or categories are allowed up to three months of retroactive
medicaid:
(1) FFS
individuals: Individuals not
enrolled in managed care during the month of application or month prior are
allowed up to three months of retroactive medicaid prior to the application
month for the following categories:
(a) other adults (COE 100);
(b) parent caretaker (COE 200);
(c) SSI
(COEs (001, 003, and 004);
(d) SSI
extensions (COEs 001, 003, and 004, e.g. 503s, disabled adult children, ping
pongs, and early widowers);
(e) WDI
(COE 074);
(f) BCC
(COE 052);
(2) pregnant women (COE 300);
(3) pregnancy-related
services (COE 301);
(4) a woman who is pregnant on any medicaid category during the
application month excluding categories that do not have retroactive medicaid
per Subsection G of 8.200.400.14 NMAC.
(5) children
under age 19 on any medicaid category, inclusive of the month a child turns age
19 during the application month, excluding categories that do not have
retroactive medicaid per Subsection G of 8.200.400.14 NMAC;
(6) family planning (COE 029);
(7) specified low income medicare beneficiaries (SLIMB COE 045)
and qualified individuals (QI1 COE 042);
(8) qualified disabled working individuals (QD COE 050);
(9) refugee (COE 049)
(10) children, youth and families department medicaid categories
(COEs 017, 037, 046, 047, 066, and 086); and
(11) institutional care medicaid (COEs 081, 083, and 084)
excluding the program of all-inclusive care for the elderly (PACE).
(12) an incarcerated individual suspended during the application
month who is FFS, pregnant, or eligible under one of the categories listed in
Subsection F of 8.200.400.14 NMAC is allowed up to three months of retroactive medicaid
prior to the application month.
G. The following
categories do not have retroactive medicaid:
(1) emergency medical services for aliens (EMSA COE 085). EMSA provides coverage for emergency services,
which may be provided prior to the application month, but is not considered
retroactive medicaid. Eligibility is
determined in accordance with 8.285.400, 8.285.500, and 8.285.600 NMAC;
(2) home and community based-services waivers (COEs 091, 093,
094, 095, and 096);
(3) other adults (COE 100) with an FPL greater than one hundred
percent who apply on or after July 1, 2019 are subject to a premium. Individuals who have a premium requirement are
determined prospectively eligible for the other adults
category.
(4) PACE
(COEs 081, 083, and 084);
(5) qualified medicare beneficiaries (COEs 041 and 044); and
(6) transitional medicaid (COEs 027 and 028).
H. Newborns (COE
031) are deemed to have applied and been found eligible for the newborn
category of eligibility from birth through the month of the child’s first
birthday. This applies in instances
where the labor and delivery services were furnished prior to the date of the
application and covered by medicaid based on the mother applying for up to
three months of retroactive eligibility.
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8.200.400.15 NMAC [RESERVED]
8.200.400.16 NMAC [RESERVED]
HISTORY OF 8.200.400 NMAC: The material in this part was derived from that previously filed with the State Records Center:
8 NMAC 4.MAD.400, Recipient Policies, Recipient Rights and Responsibilities, filed 12/30/1994.
History of Repealed Material:
8.200.400 NMAC, General Medicaid Eligibility, filed 6/15/2001 - Repealed effective 1/1/2014.
8.200.400 NMAC, General Medicaid Eligibility, filed 12/2/2013 - Repealed effective 10/1/2017.
8.200.400 NMAC, General Medicaid Eligibility, filed 9/14/2017 - Repealed effective 1/1/2019.
NMAC History:
8.200.400 NMAC, General
Medicaid Eligibility, filed 12/2/2013 was
replaced by 8.200.400 NMAC, General Medicaid Eligibility effective 10/1/2017.
8.200.400 NMAC, General
Medicaid Eligibility, filed 9/14/2017 was
replaced by 8.200.400 NMAC, General Medicaid Eligibility effective 1/1/2019.