New Mexico Register / Volume XXXIII, Issue 23
/ December 13, 2022
This is an
amendment to 8.200.400 NMAC, Sections 10 and 13, effective 1/1/2023.
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] their 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 non-citizens (EMSNC):
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 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]
12 months from their date of entry to the United States (U.S.) when they
do not qualify for other medicaid categories of
eligibility. [A] An 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] An 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; A, 1/1/2023]
8.200.400.13 AUTHORIZED REPRESENTATIVE: HSD must permit applicants and beneficiaries to designate an individual or organization to act responsibly on their behalf in assisting with the individual’s application and renewal of eligibility and other ongoing communications.
A. Such a designation must be in writing including the applicant’s signature, and must be permitted at the time of application and at other times. Legal documentation of authority to act on behalf of an applicant or beneficiary under state law, such as a court order establishing legal guardianship or a power of attorney, shall serve in the place of written authorization by the applicant or beneficiary.
B. Representatives may be authorized to:
(1) sign an application on the applicant’s behalf;
(2) complete and submit a renewal form;
(3) receive copies of the applicant or beneficiary’s notices and other communications from the agency; and
(4) act on behalf of the applicant or beneficiary in all other matters with the agency.
C. The
power to act as an authorized representative is valid until the applicant or
beneficiary modifies the authorization or notifies the agency that the
representative is no longer authorized to act on [his or her] their
behalf, or the authorized representative informs the agency that [he or she
is] they are no longer acting in such capacity, or there is a change
in the legal authority upon which the individual’s or organization’s authority
was based. Such notice must be in
writing and should include the applicant or authorized representative’s
signature as appropriate.
D. The
authorized representative is responsible for fulfilling all responsibilities
encompassed within the scope of the authorized representation to the same
extent as the individual [he or she represents] they represent,
and must agree to maintain, or be legally bound to maintain, the
confidentiality of any information regarding the applicant or beneficiary
provided by the agency.
E. As
a condition of serving as an authorized representative, a provider, staff
member or volunteer of an organization must sign an agreement that [he or
she] they will adhere to the regulations relating to confidentiality
(relating to the prohibition against reassignment of provider claims as
appropriate for a health facility or an organization acting on the facility’s
behalf), as well as other relevant state and federal laws concerning conflicts
of interest and confidentiality of information (42 CFR 435.923).
[8.200.400.13 NMAC - Rp, 8.200.400.13 NMAC, 1/1/2019; A, 1/1/2023]