New Mexico Register / Volume XXIX, Issue 8 / April 24, 2018

TITLE 8 SOCIAL SERVICES

CHAPTER 308 MANAGED CARE PROGRAM

PART 6 ELIGIBILITY

8.308.6.1 ISSUING AGENCY: New Mexico Human Services Department (HSD).

[8.308.6.1 NMAC - Rp, 8.308.6.1 NMAC, 5/1/2018]

8.308.6.2 SCOPE: This rule applies to the general public.

[8.308.6.2 NMAC - Rp, 8.308.6.2 NMAC, 5/1/2018]

8.308.6.3 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.

[8.308.6.3 NMAC - Rp, 8.308.6.3 NMAC, 5/1/2018]

8.308.6.4 DURATION: Permanent.

[8.308.6.4 NMAC - Rp, 8.308.6.4 NMAC, 5/1/2018]

8.308.6.5 EFFECTIVE DATE: May 1, 2018, unless a later date is cited at the end of a section.

[8.308.6.5 NMAC - Rp, 8.308.6.5 NMAC, 5/1/2018]

8.308.6.6 OBJECTIVE: The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance programs.

[8.308.6.6 NMAC - Rp, 8.308.6.6 NMAC, 5/1/2018]

8.308.6.7 DEFINITIONS: [RESERVED]

8.308.6.8 [RESERVED]

[8.308.6.8 NMAC - Rp, 8.308.6.8 NMAC, 5/1/2018]

8.308.6.9 MANAGED CARE ELIGIBILITY:

A. General requirements: HSD determines eligibility for medicaid. An eligible recipient is required to participate in a HSD managed care program unless specifically excluded as listed below. Enrollment in a particular managed care organization (MCO) will be according to the eligible recipient’s selection of a MCO at the time of application for eligibility, or during other permitted selection periods, or as assigned by HSD, if the eligible recipient makes no selection.

B. The following eligible recipients, as established by their eligibility category, are excluded from managed care enrollment:

(1) qualified medicare beneficiaries (QMB)-only recipients;

(2) specified low income medicare beneficiaries;

(3) qualified individuals;

(4) qualified disabled working individuals;

(5) refugees;

(6) participants in the program of all inclusive care for the elderly (PACE);

(7) children and adolescents in out-of-state foster care or adoption placements.; and

(8) family planning-only eligible recipients.

C. Native Americans may opt into managed care. If a native American is dually-eligible or in need of long-term care services, he or she is required to enroll in a MCO.

D. For those individuals who are not otherwise eligible for medicaid and who meet the financial and medical criteria established by HSD, HSD or its authorized agent may further determine eligibility for managed care enrollment through a waiver allocation process contingent upon available funding and enrollment capacity.

[8.308.6.9 NMAC - Rp, 8.308.6.9 NMAC, 5/1/2018]

8.308.6.10 SPECIAL SITUATIONS:

A. HSD has established newborn eligibility criteria.

(1) When a child is born to a member enrolled in a MCO, the hospital or other providers will complete a MAD Form 313 (notification of birth) or its successor, prior to or at the time of discharge. HSD shall ensure that upon receipt of the MAD Form 313 and upon completion of the eligibility process, the newborn is enrolled into his or her mother’s MCO. The newborn is eligible for a period of 13 months, starting with the month of his or her birth.

(2) When the newborn’s mother is covered by health insurance through the New Mexico health insurance exchange and the mother’s qualified health plan is also a HSD-contracted MCO, HSD will enroll the newborn into the mother’s MCO as of the month of his or her birth.

(3) When the newborn member’s mother is covered by health insurance through New Mexico health insurance exchange and the mother’s qualified health plan is not a HSD-contracted MCO, HSD shall auto-assign and enroll the newborn in a medicaid MCO as of the month of his or her birth. The newborn's parent or legal guardian will have one opportunity during the three month period from the effective date of enrollment to change the newborn’s MCO assignment.

B. Community benefit eligibility:

(1) A member who meets a nursing facility (NF) level of care (LOC) and who does not reside in a NF will be eligible to receive home and community-based services and may choose to receive such services either through an agency-based or self-directed model according to the self-direction criteria as outlined in 8.308.12 NMAC.

(2) An individual who is not otherwise eligible for medicaid services but meets certain financial requirements and has a NF LOC determination may be eligible for enrollment through a waiver allocation process, contingent upon funding and enrollment capacity.

[8.308.6.10 NMAC - Rp, 8.308.6.10 NMAC, 5/1/2018]

HISTORY OF 8.308.6 NMAC: [RESERVED]

History of Repealed Material:

8.308.6 NMAC - Managed Care Program, Eligibility, filed 12/17/2013 Repealed effective 5/1/2018.