TITLE 8                 SOCIAL SERVICES




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]