New Mexico Register / Volume XXXII, Issue 7 /April 6, 2021
This is an amendment to 8.281.400 NMAC, Sections 1, 8, 10–12,
14-20, 21 and 23 effective 5/1/2021.
8.281.400.1 ISSUING AGENCY: New Mexico Human Services Department (HSD).
[8.281.400.1 NMAC - Rp, 8.281.400.1 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.8 [RESERVED] MISSION
STATEMENT: 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.
[8.281.400.8 NMAC - N, 5/1/2021]
8.281.400.10 BASIS
FOR DEFINING THE GROUP: An [applicant/recipient]
applicant or recipient must require institutional care as certified by a
physician licensed to practice medicine or osteopathy. The [applicant/recipient] applicant
or recipient must be institutionalized in a medicaid
qualifying bed in a New Mexico medicaid approved
institution or in a hospital administered under the authority of the US
department of veterans affairs (VA). Medicaid
approved “Institutions” are defined as acute care hospitals (ACHs), nursing
facilities (NFs) and intermediate care facilities for individuals with
intellectual disabilities (ICF/IID), swing beds and certified instate inpatient
rehabilitation centers. Level of care
(LOC) determinations for institutional care medicaid
eligibility are made by the MAD utilization review (UR) contractor or a
member's selected or assigned Managed Care Organization (MCO). Documentation of these determinations is
provided to the institution by the UR contractor or MCO. For [applicants/recipients] applicants
or recipients in a hospital awaiting placement in NFs, confirmation letters
are furnished by the MAD UR contractor for use by hospital staff. A level of care (LOC) is not required for
acute care hospitals. Documentation of
acute care hospitalization must be provided by the hospital to determine the
eligibility period.
[8.281.400.10 NMAC - Rp, 8.281.400.10 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.11 INTERVIEW
REQUIREMENTS:
[ A. Purpose and scope of interview: An
interview is required at initial application for institutional care medicaid. The
initial interview is an official and confidential discussion of household
circumstances with the applicant. The
interview is intended to provide the applicant with program information, and to
supply the facts needed by the income support division (ISD) worker to make a
reasonable eligibility determination. The
interview is not simply to review the information on the application, but also
to explore and clarify any unclear or incomplete information. The scope of the interview shall not extend
beyond examination of the applicant's circumstances that are directly related
to determining eligibility. The
interview shall be held prior to disposition of the application.
B. Individuals interviewed: Applicants, including those who submit
applications by mail, shall be
interviewed via telephone with an ISD worker. When circumstances warrant or upon request of
the applicant, the household may be interviewed in person at another place
reasonably accessible and agreeable to both the applicant and the ISD worker. The applicant may bring any person he chooses
to the interview.
C. Scheduling interviews: The interview on an initial application
shall be scheduled within 10
working days, and, to the extent possible, at a
time that is most convenient for the applicant.
D. Missed interviews: ISD shall notify a household that
it missed its first interview appointment, and inform the household that it is
responsible for rescheduling the missed interview. If the household contacts the caseworker
within the 45-day application processing period, the caseworker shall schedule
a second interview. When the applicant
contacts ISD, either orally or in writing, the caseworker shall reschedule the
interview as
soon as possible thereafter within the 45-day
processing period, without requiring the applicant to provide good
cause for missing the initial interview. If the applicant does not contact ISD or does
not appear for the rescheduled
interview, the application shall be denied on the
45th day (or the next work day) after the application was filed.]
An interview is not required for institutional care medicaid. An
applicant or recipient can request an interview from the income support
division (ISD).
[8.281.400.11 NMAC - Rp, 8.281.400.11 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.12 ENUMERATION: An [applicant/recipient] applicant
or recipient must furnish his or her social security number in accordance
with 8.200.410.10 NMAC.
[8.281.400.12 NMAC - Rp, 8.281.400.12 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.14 RESIDENCE:
A. Residence
in the United States: An [applicant/recipient]
applicant or recipient must be residing in the United States at the time
of approval. An [applicant/recipient]
applicant or recipient who leaves the United States for an entire calendar
month loses eligibility. The [applicant/recipient]
applicant or recipient must re-establish [his/her] their
residence in the United States for at least 30 consecutive days before becoming
eligible for any SSI-related medicaid program.
B. Residence
in New Mexico: To be eligible for
institutional care medicaid, an [applicant/recipient]
applicant or recipient must be physically present in New Mexico on the
date of application or final determination of eligibility and must have
demonstrated intent to remain in the state.
If the individual does not have the present mental capacity to declare
intent, the parent, guardian or adult child may assume responsibility for a
declaration of intent. If the individual
does not have the present mental capacity to declare intent and there is no
guardian or relative to assume responsibility for a declaration of intent, the
state where the person is living is recognized as the state of residence. A temporary absence from the state does not
preclude eligibility. A temporary
absence exists if the [applicant/recipient] applicant or recipient
leaves the state for a specific purpose with a time-limited goal and intends to
return to New Mexico when the goal is accomplished.
[8.281.400.14 NMAC - Rp, 8.281.400.14 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.15 SPECIAL
RECIPIENT REQUIREMENTS: [To be eligible for
institutional care medicaid, an applicant/recipient
must be aged, blind, or disables as defined by the social security
administration (SSA). Recipients of
institutional care medicaid in New Mexico are
terminated from assistance if they are transferred to, or choose to move to, a
long term care facility out-of-state.
New Mexico medicaid does not cover NF services
furnished to applicants/recipients in out-of-state facilities.]
A. Institutional care medicaid: To be
eligible for institutional care medicaid an applicant
or recipient must be aged, blind, or disabled as defined by the social security
administration (SSA). Recipients of
institutional care medicaid in New Mexico are
terminated from assistance if they are transferred to, or choose to move to, a
long term care facility out-of-state.
New Mexico medicaid does not cover NF services
furnished to applicants or recipients in out-of-state facilities.
B. Intermediate care facilities for individuals
with intellectual disabilities (ICF/IID): To be eligible for an ICF/IID, applicants or recipients
must obtain a match letter from the department of health to confirm that he or
she meets the definition of an individual with a developmental disability as
determined by the department of health/developmental disabilities supports
division, in accordance with 8.290.400.10 NMAC.
[8.281.400.15 NMAC - Rp, 8.281.400.15 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.16 AGED: To be considered aged, an [applicant/recipient
individmust] applicant or recipient must
be 65 years of age or older. Age is
verified by the following:
A. decision from SSA regarding age;
B. acceptable documentary evidence including:
(1) birth certificate or delayed birth certificate;
(2) World War II ration books;
(3) baptismal records;
(4) marriage license or certificate;
(5) military discharge papers;
(6) insurance policies;
(7) Indian census records;
(8) dated newspaper clippings;
(9) voting registration;
(10) World War I registration;
(11) veterans administration records; or
(12) school census.
[8.281.400.16 NMAC - Rp, 8.281.400.16 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.17 BLIND: To be considered blind, an [applicant/recipient]
applicant or recipient must have central visual acuity of 20/200 or less
with corrective lenses.
A. Documentation
of blindness: An [applicant/recipient]
applicant or recipient must meet the SSA’s definition of blindness. If [he/she] the applicant or
recipient is receiving social security or supplemental security income
(SSI) benefits based on the condition of blindness, verification of this factor
can be accomplished through documents, such as award letters or benefit checks.
B. Status
of SSA determination: If it has not
been determined whether an [applicant/recipient] applicant or
recipient meets SSA’s definition of blindness or if only a temporary
determination was made, the ISD worker must request a determination from the
disability determination unit (DDU).
Eligibility based on blindness cannot be considered to exist without a
DDS determination.
C. Redetermination
of blindness: A redetermination of
blindness by the DDU is not required on a re-application following an [applicant/recipient’s]
applicant or recipient’s termination from SSI/SSA or medicaid,
if a permanent condition of blindness was previously established or the
termination was based on a condition unrelated to blindness and there was no
indication of possible improvement in an [applicant/recipient’s] applicant
or recipient’s vision.
D. Remedial
treatment: If the DDU recommends
remedial medical treatment that carries no more than the usual risk or a
reasonable plan for vocational training, an [applicant/recipient] applicant
or recipient must comply with the recommendation unless good cause for not
doing so exists.
[8.281.400.17 NMAC - Rp, 8.281.400.17 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.18 DISABILITY: To be considered disabled, an [applicant/recipient]
applicant or recipient under 65 years of age is considered to have a
qualifying disability if [he/she is] they are unable to engage in
any substantial gainful activity because of any medically determinable
physical, developmental, or mental impairment which has lasted, or is expected
to last, for a continuous period of at least 12 months.
A. Documentation
of disability: An [applicant/recipient]
applicant or recipient must meet the social security administration
(SSA)’s definition of disability. If [he/she]
the applicant or recipient is receiving social security or supplemental
security income (SSI) benefits based on the condition of disability,
verification of this factor can be accomplished through documents, such as
award letters or benefit checks.
B. Status
of SSA determination: If it has not
been determined whether an [applicant/recipient] applicant or
recipient meets the SSA’s definition of disability or if only a temporary
determination was made, the ISS must request a determination from the DDU. Eligibility based on disability cannot be
considered to exist without a DDS determination.
C. Redetermination
of disability: A redetermination of
disability by the DDU is not required on a re-application following an [applicant/recipient’s]
applicant or recipient’s termination from SSI/SSA or medicaid,
if a permanent condition of disability was previously established or the
termination was based on a condition unrelated to disability and there was no
indication of possible improvement in an applicant/recipient’s physical
condition.
D. Remedial
treatment: If the DDU recommends
remedial medical treatment that carries no more than the usual risk or a
reasonable plan for vocational training, an [applicant/recipient] applicant
or recipient must comply with the recommendation unless good cause for not
doing so exists.
[8.281.400.18 NMAC - Rp, 8.281.400.18 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.19 SSI
STATUS: The ISD worker determines
whether an [applicant/recipient’s] applicant or recipient’s SSI
eligibility will continue while [he/she is] they are
institutionalized.
A. Applicant/recipient
currently eligible for SSI: If an [applicant/recipient]
applicant or recipient will not continue to be eligible for SSI while
institutionalized, the ISD worker processes the application regardless of the
fact that SSA will not terminate SSI benefits until the month following the
month the [applicant/recipient] applicant or recipient enters an
institution.
B. Applicant
not currently receiving SSI: If an [applicant/recipient]
applicant or recipient is not receiving SSI or has not applied for SSI
before applying for medicaid and [his/her] their
gross income is less than $50, the ISD worker processes the application and
refers the applicant to the SSA for determination of eligibility for SSI
benefits. If an applicant’s gross
monthly income is $50 or more but not in excess of the maximum allowable income
standard, the ISD worker determines eligibility for institutional care medicaid based on remaining financial and nonfinancial
criteria.
[8.281.400.19 NMAC - Rp, 8.281.400.19 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.20 RECIPIENT
RIGHTS AND RESPONSIBILITIES: An [applicant/recipient]
applicant or recipient is responsible for establishing [his/her] their
eligibility for medicaid. As part of this
responsibility, the [applicant/recipient] applicant or recipient must
provide required information and documents or take the actions necessary to
establish eligibility. Failure to do so
must result in a decision that eligibility does not exist. An [applicant/recipient] applicant
or recipient must also grant the [human services department (HSD)] HSD
permission to contact other persons, agencies or sources of information, which
are necessary to establish eligibility.
[8.281.400.20 NMAC - Rp, 8.281.400.20 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.21 RIGHT
TO HEARING: An [applicant/recipient]
applicant or recipient residing in an institution can request an
administrative hearing to dispute issues relating to the eligibility
determination process at the time of the eligibility determination (see Section
8.200.430.12 NMAC, Right to Hearing).
[8.281.400.21 NMAC - Rp, 8.281.400.21 NMAC, 1/1/2019; A, 5/1/2021]
8.281.400.23 REPORTING
REQUIREMENTS: Medicaid recipients
must report any change in circumstances, which may affect [his/her] their
eligibility to their local [income support division (ISD)] ISD
office within 10 days of the change in accordance with 8.200.430.18 NMAC.
[8.281.400.23 NMAC - Rp, 8.281.400.23 NMAC, 1/1/2019; A, 5/1/2021]