TITLE 8 SOCIAL SERVICES
CHAPTER 171 PREMIUM
ASSISTANCE FOR CHILDREN (CATEGORY 071/2)
PART 400 RECIPIENT
POLICIES
8.171.400.1 ISSUING
AGENCY: Human Services Department
[8.171.400.1 NMAC - N/E,
8-31-06]
8.171.400.2 SCOPE: This rule
applies to the general public.
[8.171.400.2 NMAC - N/E,
8-31-06]
8.171.400.3 STATUTORY
AUTHORITY: New Mexico Statutes Annotated, 1978 (Chapter
27, Article 2-12) authorizes the human services department to administer a
program of medical or premium assistance for children and pregnant women
ineligible for federally funded public assistance. The premium assistance for kids program will
be designated for purposes of this regulation as category 071.
[8.171.400.3 NMAC - N/E,
8-31-06]
8.171.400.4 DURATION: Permanent.
[8.171.400.4 NMAC - N/E,
8-31-06]
[The medical or premium
assistance program is operated subject to the availability of funding.]
8.171.400.5 EFFECTIVE
DATE:
August 31, 2006, unless a later date is cited at the end of the section.
[8.171.400.5 NMAC - N/E,
8-31-06]
8.171.400.6 OBJECTIVE: The objective
of premium assistance for kids is to reduce the number of uninsured New
Mexicans by providing state funds toward the purchase of comprehensive health
insurance products to children up to the age of twelve, and children up to the
age of eighteen if part of a sibling group that includes a child up to the age
of twelve, who are ineligible for public assistance under the act.
[8.171.400.6 NMAC - N/E,
8-31-06]
8.171.400.7 DEFINITIONS:
A. Action:
The denial or limited authorization of a requested service, including
the type or level of service; the reduction, suspension, modification, or
termination of a previously authorized service; the denial, in whole or in
part, of payment for a service; or a failure to provide a service in a timely
manner. An untimely service
authorization constitutes a denial and is thus considered an action.
B. Administrative hearing: An evidentiary hearing conducted so that
evidence can be presented.
C. Certification of comprehensive health plan: The process by which the human services
department (HSD) certifies an insurance plan as a comprehensive plan eligible
for participation in the premium assistance program.
D. Enumeration: The process by which the federal government assigns
a social security number.
E. Overpayments: Erroneous payments or payment made on behalf
of an individual was not eligible.
F. Sibling group: Siblings, including half- or step-siblings,
living in the same household.
[8.171.400.7 NMAC - N/E, 8-31-06]
8.171.400.8 [RESERVED]
8.171.400.9 WHO
CAN BE COVERED UNDER PREMIUM ASSISTANCE PROGRAM: To be eligible
for premium assistance for kids, the applicant must meet all eligibility
criteria and must enroll in (or be enrolled in), a comprehensive health care
plan for children certified by HSD.
[8.171.400.9 NMAC - N/E,
8-31-06]
8.171.400.10 ELIGIBILITY: To be eligible
for premium assistance for kids, the applicant must meet all eligibility
criteria. Once eligibility is
established, the individual enrolls in and makes premium payment to a certified
comprehensive health insurance plan.
[8.171.400.10 NMAC - N/E,
8-31-06]
8.171.400.11 HEALTH
CARE PLAN ELIGIBILITY: In order to participate in premium assistance
for kids, a health plan must be certified by HSD as a comprehensive health plan
for children. An individual who is
determined to be eligible for premium assistance for kids will continue to be
eligible for a period of 12 months as long as health insurance enrollment
continues, or until the participant(s) no longer meet(s) age criteria, moves
out of state, or the participant’s income changes, the information is reported
to HSD, and the individual becomes eligible for medicaid or SCHIP.
[8.171.400.11 NMAC - N/E,
8-31-06]
8.171.400.12 ENROLLMENT: Premium
assistance for kids payments will not begin until the individual has been found
eligible and enrolls in a comprehensive health plan for children certified by
the department. Once the individual is
enrolled and premium assistance has begun to make payments, the individual may
not switch to another insurer for a period of 12 consecutive months, unless
good cause to switch enrollment is established.
A request to switch enrollment from one plan certified by HSD as a certified
comprehensive health plan to another by an eligible premium assistance for kids
participant must be submitted in writing to HSD. HSD shall review the request and determine
whether good cause for the switch exists.
The participant will be notified of the decision in writing within a 30
day period. The existence of good cause
will be determined using the following criteria:
A. continuity
of care issues;
B. family
continuity;
C. administrative
or data entry error in enrolling a member with a health plan; and
D. travel
for primary care exceeds the following standards: urban residents shall travel no further than
30 miles to see a primary care provider (PCP); rural residents shall travel no
more than 45 miles to see a PCP, and frontier residents shall travel no more
than 60 miles to see a PCP; urban counties are: Bernalillo, Los Alamos, Santa
Fe, and Dona Ana; frontier counties are:
Catron, Harding, DeBaca, Union, Guadalupe, Hidalgo, Socorro, Mora,
Sierra, Lincoln, Torrance, Colfax, Quay, San Miguel, and Cibola; rural counties
are all others not listed as urban or frontier.
[8.171.400.12 NMAC - N/E,
8-31-06]
8.171.400.13 DISENROLLMENT: Once a premium
assistance for kids enrollee disenrolls from the certified health plan or fails
to pay the non-subsidized portion of the premium, he will become ineligible for
premium assistance for kids for a period of 12 months, starting with the first
month in which the coverage was dropped (i.e., the first month in which the
individual has no coverage).
[8.171.400.13 NMAC - N/E,
8-31-06]
8.171.400.14 [RESERVED]
8.171.400.15 RESIDENCY: To be eligible for premium assistance for
kids, applicant/recipients must be living in New Mexico on the date of
application or determination of eligibility and have demonstrated intent to
remain in New Mexico.
A. Establishing residence: Residence in New Mexico is established by
living in the state and carrying out the types of activities normally
associated with every day life, such as occupying a home, enrolling child(ren)
in school, getting a driver’s license, or renting a post office box. An applicant/recipient who is homeless is
considered to have met residency requirements if he intends to remain in the
state.
B. Abandonment of residence: Residence is not abandoned by temporary
absences from the state. Temporary
absences occur when recipients leave New Mexico for specific purposes with
time-limited goals. Residence is
considered abandoned when any of the following occur:
(1) applicant/recipient leaves New Mexico and
indicates that he intends to establish residence in another state;
(2) applicant/recipient leaves New Mexico for
no specific purpose with no clear intention of returning;
(3) applicant/recipient leaves the state and
applies for financial, food, or medical assistance in another state that makes
residence a condition of eligibility; or
(4) applicant/recipient has been absent from
New Mexico for more than 30 days without notification of departure to intention
of returning.
[8.171.400.15 NMAC - N/E,
8-31-06]
8.171.400.16 RESIDENCE
IN A PUBLIC INSTITUTION: An applicant/recipient who is an inmate of a
public institution is not eligible for premium assistance for kids. A public institution is an institution which
is the responsibility of a governmental unit and over which a governmental unit
exercises administrative control.
A. Public
institutions include jails, prisons, detention centers, diagnostic holding
centers, the New Mexico boys and girls schools, “wilderness camps”, or halfway
houses and reintegration centers which are not certified to furnish medical
care.
B. An
individual is not considered to be living in an institution if he is placed in
a detention center for a temporary period pending other arrangements
appropriate to his needs. For purposes
of eligibility for premium assistance for kids, an individual who is placed in
a detention center is considered temporarily absent from the home, until the 60th
day, or the adjudication ends, whichever first occurs.
[8.171.400.16 NMAC - N/E,
8-31-06]
8.171.400.17 SPECIAL RECIPIENT REQUIREMENTS: To be eligible
for premium assistance for kids, the applicant must meet the following
criteria:
A. Age: For purposes of premium assistance for kids eligibility, the applicant must be less
than 12 years of age, or less than the age of 18 if part of a sibling group
that includes a child up to the age of 12.
B. Continuing
eligibility on the basis of age:
When an individual has been determined eligible based on age, he remains
eligible on the condition of age until the upper age limit, as described above,
is reached. An individual who exceeds
the age limit during a given month is eligible for that month, unless the
birthday is the first day of the month.
C. Uninsured: For purposes of premium assistance for kids
eligibility, an applicant cannot be covered by a commercial health insurance
product, medicare, or medicaid. The
applicant must be ineligible for medicaid or SCHIP due to countable income, not
on the basis of failure to recertify or failure to provide the necessary
documentation to establish eligibility for medicaid or SCHIP. An individual with access to health care at
Indian health services, veteran’s administration, or through worker’s compensation,
is not considered to be insured by having such access.
D. Voluntary
drop of insurance:
(1) An individual who has
voluntarily dropped health insurance, or whose parent or stepparent has dropped
health insurance on the child’s behalf, will be ineligible for premium
assistance for kids for six months,
starting with the month that the health insurance was dropped (i.e., the first
month of no coverage). It is not
considered to be a voluntary drop if the drop was caused by: the loss of access to employer-sponsored
insurance, the loss of employment, divorce, death of a spouse, geographic move,
or loss of coverage as a dependent child.
(2) If the client share of the
premium assistance for kids premium is not made on time and the client is
disenrolled, there will be a 12 month period of ineligibility.
E. Ineligible for medicaid or SCHIP: To be eligible for premium assistance for
kids, the applicant must either be denied for medicaid and SCHIP or be screened
and found ineligible for medicaid and SCHIP.
[8.171.400.17 NMAC - N/E,
8-31-06]
8.171.400.18 CITIZENSHIP: See
8.200.410.11 NMAC.
[8.171.400.18 NMAC - N/E,
8-31-06]
8.171.400.19 ENUMERATION: In order to be
eligible for premium assistance for kids, the individual must disclose his or
her social security number, or apply for one if not already enumerated.
[8.171.400.19 NMAC - N/E,
8-31-06]
HISTORY OF 8.171.400
NMAC:
[RESERVED]