New Mexico Register / Volume XXXI, Issue 2 /
January 28, 2020
This is an amendment
to 8.200.400 NMAC, Section 14, effective 2/1/2020.
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).] Retroactive medicaid is allowed for up to three months prior to the
application month for the following medicaid
categories:
(1) other adults (COE 100);
(2) parent caretaker (COE 200)
(3) pregnant women (COE 300);
(4) pregnancy-related
services (COE 301);
(5) children under age 19 (COEs 400, 401, 402, 403, 420, and
421);
(6) family planning (COE 029);
(7) children, youth and families department (CYFD COEs 017, 037,
046, 047, 066, and 086);
(8) supplemental security income (SSI COEs 001, 003, and 004);
(9) SSI
(COEs 001, 003, and 004, e.g. 503s, disabled adult children, ping pongs, and
early widowers);
(10) working disabled individuals (COE 074);
(11) breast and cervical cancer (BCC COE 052);
(12) specified low income beneficiaries (SLIMB COE 045);
(13) qualified individuals (QI1 COE 042);
(14) qualified disabled working individuals (COE 050);
(15) refugees (COE 049); and
(16) institutional care medicaid (COEs
081, 083, and 084) excluding the program for all-inclusive care for the elderly
(PACE).
E. 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) PACE
(COEs 081, 083, and 084);
(4) qualified medicare beneficiaries
(COEs 041 and 044); and
(5) transitional medicaid (COEs 027
and 028).
[H.] F. 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.
[8.200.400.14 NMAC -
Rp, 8.200.400.14 NMAC, 1/1/2019; A, 2/1/2020]