New Mexico Register / Volume XXIX, Issue 23 / December 11, 2018

This is an amendment to 8.308.6 NMAC, Sections 9, 10 and part name, effective 1/1/2019.

TITLE 8 SOCIAL SERVICES

CHAPTER 308 MANAGED CARE PROGRAM

PART 6 [ELIGIBILITY] MANAGED CARE ORGANIZATION (MCO) ENROLLMENT

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 (SLIMB) only;

(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; A, 1/1/2019]

8.308.6.10 SPECIAL SITUATIONS:

A. HSD [has established] newborn [eligibility] enrollment criteria.

(1) When a child is born to a member enrolled in a MCO, the hospital or other providers will complete a MAD [Form] 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] 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.]

(4) The newborn member’s parent or legal guardian will have three months from the first day of the month of birth to change the newborn’s MCO assignment. After the three month period, the newborn’s MCO enrollment may only be changed for cause, as set forth in Paragraph (2) of Subsection H of 8.308.7.9 NMAC.

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 [modelaccording to the self-direction criteria] approach 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.] Members who meet NFLOC and are eligible to receive community benefits must be enrolled in a centennial care MCO.

[8.308.6.10 NMAC - Rp, 8.308.6.10 NMAC, 5/1/2018; A, 1/1/2019]