TITLE 8 SOCIAL SERVICES
CHAPTER 172 PREMIUM
ASSISTANCE FOR MATERNITY (CATEGORY 035/2)
PART 400 RECIPIENT
POLICIES
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]
8.172.400.17 RESIDENCE
IN A PUBLIC INSTITUTION:
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]
HISTORY OF 8.172.400
NMAC:
[RESERVED]