New Mexico Register / Volume XXXII, Issue 24
/ December 28, 2021
This is an
amendment to 8.200.400 NMAC, Sections 8, 10 and 14, effective 1/1/2022.
8.200.400.8 [RESERVED] MISSION: To transform lives. Working with our partners, we design and
deliver innovative, high quality health and human services that improve the
security and promote independence for New Mexicans in their communities.
[8.200.400.8 NMAC - Rp, 8.200.400.8 NMAC, 1/1/2019; A, 1/1/2022]
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)] non-citizens (EMSNC): [EMSA] EMSNC medicaid covers
certain non-citizens 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] EMSNC 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.
[8.200.400.10 NMAC -
Rp, 8.200.400.10 NMAC, 1/1/2019; A, 1/1/2022]
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
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] non-citizens ([EMSA] EMSNC
COE 085). [EMSA] EMSNC 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).
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; A, 1/1/2022]