TITLE 8                 SOCIAL SERVICES




8.172.400.1          ISSUING AGENCY:  Human Services Department

[8.172.400.1 NMAC - N/E, 12-31-06]


8.172.400.2          SCOPE:  This rule applies to the general public.

[8.172.400.2 NMAC - N/E, 12-31-06]


8.172.400.3          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 pregnant women ineligible for federally funded public assistance.  The premium assistance for maternity program will be designated for purposes of this policy as category 035/2.

[8.172.400.3 NMAC - N/E, 12-31-06]


8.172.400.4          DURATION:  The medical or premium assistance program is operated subject to the availability of funding.

[8.172.400.4 NMAC - N/E, 12-31-06]


8.172.400.5          EFFECTIVE DATE:  December 31, 2006, unless a later date is cited at the end of the section.

[8.172.400.5 NMAC - N/E, 12-31-06]


8.172.400.6          OBJECTIVE:  The objective of premium assistance for maternity is to reduce the number of uninsured New Mexicans by providing state funds toward the purchase of comprehensive health insurance products for pregnant women who are ineligible for public assistance under the act.

[8.172.400.6 NMAC - N/E, 12-31-06]


8.172.400.7          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.            Enrollment:  For purposes of premium assistance for maternity, “enrollment” means payment of the premium assistance for maternity one-time premium.

                D.            Enumeration:  The process by which the federal government assigns a social security number.

                E.             Public institution:  An institution which is the responsibility of a governmental unit and over which a governmental unit exercises administrative control.  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.

                F.             Overpayments:  Erroneous payments or payment made on behalf of an individual was not eligible.

                G.            Uninsured:  For purposes of premium assistance for maternity, a woman is considered to be uninsured if she does not have health insurance coverage that includes prenatal and delivery care.  A woman with access to services at IHS, veterans’ administration, or workers’ compensation, or having commercial health insurance that excludes prenatal and delivery benefits, is not considered to be insured.

[8.172.400.7 NMAC - N/E, 12-31-06]


8.172.400.8          [RESERVED]


8.172.400.9          WHO CAN BE COVERED UNDER PREMIUM ASSISTANCE PROGRAM:  To be covered by premium assistance for maternity (PAM), the applicant must meet all eligibility criteria and must enroll by paying the one-time enrollment fee.

[8.172.400.9 NMAC - N/E, 12-31-06]


8.172.400.10        ELIGIBILITY:  To be eligible for PAM, the applicant must meet all eligibility criteria.  Once eligibility is established, the individual enrolls in the PAM by paying the one-time premium.

[8.172.400.10 NMAC - N/E, 12-31-06]


8.172.400.11        HEALTH CARE COVERAGE UNDER PAM:  Health care coverage under the PAM program is the HSD pregnancy-only coverage (see 8.235.600.9 NMAC [PSO 600]).

[8.172.400.11 NMAC - N/E, 12-31-06]


8.172.400.12        ELIGIBILITY:  An individual who is determined to be eligible for PAM will continue to be eligible throughout the pregnancy and through the end of the second month after the month of birth or the month of pregnancy termination, unless the woman moves out of state, or reports a decrease in income that results in the woman being found eligible for medicaid.

[8.172.400.12 NMAC - N/E, 12-31-06]


8.172.400.13        ENROLLMENT:  For purposes of PAM, “enrollment” in the pregnancy-related coverage will consist of paying the enrollment fee.  PAM coverage begins only after eligibility has been determined and the enrollment fee has been received by HSD.

[8.172.400.13 NMAC - N/E, 12-31-06]


8.172.400.14        DISENROLLMENT:  Once the pregnant woman is determined eligible for PAM and the one-time premium is paid, the pregnant woman is enrolled and coverage begins.  Enrollment continues until the sooner of: the second month following the month of birth or the termination of the pregnancy; the woman moves out of state; or the woman is found eligible for medicaid.  The one-time premium will not be refunded under the above-described or any other circumstances.

[8.172.400.14 NMAC - N/E, 12-31-06]


8.172.400.15        [RESERVED]


8.172.400.16        RESIDENCY:  To be eligible for PAM, 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/resident 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 thirty (30) days without notification of departure to intention of returning.

[8.172.400.16 NMAC - N/E, 12-31-06]



                A.            An applicant/recipient who is an inmate of a public institution is not eligible for PAM.  A public institution is an institution which is the responsibility of a governmental unit and over which a governmental unit exercises administrative control.

                B.            Public institutions include jails, prisons, detention centers, diagnostic holding centers, the New Mexico boy’s and girl’s schools, “wilderness camps”, or halfway houses and reintegration centers which are not certified to furnish medical care.

                C.            An individual is not considered to be living in an institution if she is placed in a detention center for a temporary period pending other arrangements appropriate to her needs.  For purposes of eligibility for PAM, a woman who is placed in a detention center is considered temporarily absent form the home, until the 60th day, or the adjudication ends, whichever first occurs.

[8.172.400.17 NMAC - N/E, 12-31-06]


8.172.400.18        SPECIAL RECIPIENT REQUIREMENTS:  To be eligible for PAM, the applicant must meet the criteria below.

                A.            Enrollment:  For purposes of PAM, enrollment consists of paying the one-time premium.  Premium charges are determined by the secretary of HSD and are subject to change pursuant to available funding.  Premium charges are constructed to provide financial incentives for early prenatal care.

                B.            Ineligible for medicaid:  To be eligible for PAM, the applicant must either be denied medicaid, or be screened and found ineligible for medicaid.

                C.            Pregnant:  For purposes of PAM, the woman must be pregnant.

                D.            Uninsured:  For purposes of PAM eligibility, an applicant cannot be covered by medicare, medicaid, or a commercial health insurance product that covers prenatal care and delivery.  The applicant must be ineligible for medicaid due to countable income, not on the basis of failure to recertify or failure to provide the necessary documentation to establish eligibility for medicaid.  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.

                E.             Voluntary drop of insurance:  A pregnant woman who has voluntarily dropped health insurance that covers prenatal care and delivery will be ineligible for PAM 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.

[8.172.400.18 NMAC - N/E, 12-31-06]


8.172.400.19        CITIZENSHIP:  Refer to 8.200.410.11 NMAC.

[8.172.400.19 NMAC - N/E, 12-31-06]


8.172.400.20        ENUMERATION:  In order to be eligible for PAM, the individual must disclose his or her social security number, or apply for one if not already enumerated.

[8.172.400.20 NMAC - N/E, 12-31-06]