TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT RULES
PART 400 GENERAL
MEDICAID ELIGIBILITY
8.200.400.1 ISSUING AGENCY: New
Mexico Human Services Department (HSD).
[8.200.400.1 NMAC -
Rp, 8.200.400.1 NMAC, 1/1/2019]
8.200.400.2 SCOPE: The
rule applies to the general public.
[8.200.400.2 NMAC -
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8.200.400.3 STATUTORY AUTHORITY: The
New Mexico medicaid program and other health care programs
are administered pursuant to regulations promulgated by the federal department
of health and human services under Title XIX of the Social Security Act as
amended or by state statute. See Section
27-1-12 et seq., NMSA 1978.
[8.200.400.3 NMAC -
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8.200.400.4 DURATION:
Permanent.
[8.200.400.4 NMAC -
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8.200.400.5 EFFECTIVE DATE: January 1, 2019, or upon a later approval date by the federal centers
for medicare and medicaid
services (CMS), unless a later date is cited at the end of the section.
[8.200.400.5 NMAC -
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8.200.400.6 OBJECTIVE: The
objective of this rule is to provide specific instructions when determining
eligibility for the medicaid program and other health
care programs. Generally, applicable
eligibility rules are detailed in the medical assistance division (MAD)
eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility.
Processes for establishing and maintaining MAD eligibility are detailed
in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance Programs.
[8.200.400.6 NMAC -
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8.200.400.7 DEFINITIONS: [RESERVED]
8.200.400.8 MISSION: To transform lives. Working with our partners, we design and
deliver innovative, high quality health and human
services that improve the security and promote independence for New Mexicans in
their communities.
[8.200.400.8 NMAC - Rp, 8.200.400.8 NMAC, 1/1/2019; A, 1/1/2022]
8.200.400.9 GENERAL
MEDICAID ELIGIBILITY: Medicaid
services are jointly financed by the federal government and the state of New
Mexico and are administered by medical assistance division (MAD).
A. Within broad
federal regulations, New Mexico determines categories of eligible recipients,
eligibility requirements, types and range of services, levels of provider
reimbursement and managed care capitation, and administrative and operating
procedures.
B. New
Mexico administers medical assistance programs using waivers of the Social
Security Act for comparability of services, rules for income and resources and
freedom of choice of provider.
C. Payments for
medical and behavioral health services, durable equipment and supplies are made
directly to service providers, not to the medicaid
eligible recipient.
D. This chapter
describes the New Mexico categories of medicaid and
medical assistance programs eligibility.
Each medicaid and medical assistance program
includes detailed eligibility requirements which are organized into the
following three chapter types:
(1) recipient
requirements (.400);
(2) income
and resources standards (.500);
and
(3) benefit
description (.600).
[8.200.400.9 NMAC -
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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 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 twelve months
from their date of entry to the United States (U.S.) when they do not qualify
for other medicaid categories of eligibility. 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). 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.
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8.200.400.11 PRESUMPTIVE ELIGIBILITY FOR BREAST AND
CERVICAL CANCER: PE provides immediate access to health
services when an individual appears to be eligible for Category 052.
A. Breast and cervical cancer (BCC) (Category 052): PE
provides temporary medicaid coverage for an uninsured
woman, under the age of 65 who has been screened and diagnosed by the DOH as
having breast or cervical cancer to include pre-cancerous conditions. Only one PE period is allowed per calendar
year.
B. PE is determined
by a qualified entity certified by HSD.
Qualified entities may include community and rural health centers,
hospitals, physician offices, local health departments, family planning
agencies and schools.
C. The PE period
begins on the date the provider determines presumptive eligibility and
terminates at the end of the following month.
D. Providers shall notify
the MAD claims processing contractor of the determination within 24-hours of
the PE determination.
E. For continued medicaid eligibility beyond the PE period, a completed and
signed application for medicaid must be submitted to
HSD/ISD. An eligible PE provider must
submit the application to ISD within 10 calendar days from the receipt of the
application.
[8.200.400.11 NMAC -
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8.200.400.12 12 MONTHS CONTINUOUS
ELIGIBILITY FOR CHILDREN (42 CFR 435.926):
A. HSD
provides continuous eligibility for the period specified in Subsection B of 8.200.400.14
NMAC for an individual who is:
(1) Under
age 19 and
(2) Eligible
and enrolled for mandatory or optional coverage under the State plan.
B. The continuous eligibility period is 12
months. The continuous eligibility
period begins on the effective date of the individual's eligibility or most
recent redetermination or renewal of eligibility.
C. A child's
eligibility may not be terminated during a continuous eligibility period,
regardless of any changes in circumstances, unless:
(1) The
child attains the maximum age of 19;
(2) The
child or child's representative requests a voluntary termination of
eligibility;
(3) The
child ceases to be a resident of New Mexico;
(4) The
agency determines that eligibility was erroneously granted at the most recent
determination, redetermination or renewal of eligibility because of agency
error or fraud, abuse, or perjury attributed to the child or the child's
representative; or
(5) The
child dies.
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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 their behalf, or the authorized representative informs the agency that 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 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 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).
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8.200.400.14 RETROACTIVE MEDICAID:
A. HSD must make
eligibility for medicaid effective no later than the
first or up to the third month before the month of application if the
individual:
(1) Requested
coverage for months prior to the application month;
(2) received
medicaid services, at any time during that period, of
a type covered under the plan and;
(3) would
have been eligible for medicaid at the time they
received the services, if they had applied (or an
authorized representative has applied for him or her) regardless of whether the
individual is alive when application for medicaid is
made.
B. Eligibility for medicaid is effective on the first day of the month if an
individual was eligible at any time during that month.
C. Eligibility for
each retroactive month is determined separately. Retroactive medicaid
must be requested within 180 days of the date of the medicaid
application.
D. Retroactive medicaid is allowed for up to three months prior to the
application month for the following medicaid
categories:
(1) other
adults (COE 100);
(2) parent
caretaker (COE 200);
(3) pregnant
women (COE 300);
(4) pregnancy-related
services (COE 301);
(5) children
under age 19 (COEs 400, 401, 402, 403, 420, and 421);
(6) family
planning (COE 029);
(7) children,
youth and families department (CYFD COEs 017, 037,
046, 047, 066, and 086);
(8) supplemental
security income (SSI COEs 001, 003, and 004);
(9) SSI
(COEs 001, 003, and 004, e.g. 503s, disabled adult children, ping pongs, and
early widowers);
(10) working
disabled individuals (COE 074);
(11) breast
and cervical cancer (BCC COE 052);
(12) specified
low income beneficiaries (SLIMB COE 045);
(13) qualified
individuals (QI1 COE 042);
(14) qualified
disabled working individuals (COE 050);
(15) refugees
(COE 049); and
(16) institutional
care medicaid (COEs 081, 083, and 084) excluding the
program for all-inclusive care for the elderly (PACE).
E. The following
categories do not have retroactive medicaid:
(1) emergency
medical services for non-citizens EMSNC (COE 085). EMSNC provides coverage for emergency
services, which may be provided prior to the application month, but is not
considered retroactive medicaid. Eligibility is determined in accordance with
8.285.400, 8.285.500, and 8.285.600 NMAC;
(2) home
and community based-services waivers (COEs 091, 093, 094, 095, and 096);
(3) PACE
(COEs 081, 083, and 084);
(4) qualified
medicare beneficiaries (COEs 041 and 044); and
(5) transitional
medicaid (COEs 027 and 028).
F. Newborns (COE
031) are deemed to have applied and been found eligible for the newborn
category of eligibility from birth through the month of the child’s first
birthday. This applies in instances
where the labor and delivery services were furnished prior to the date of the
application and covered by medicaid based on the
mother applying for up to three months of retroactive eligibility.
[8.200.400.14 NMAC -
Rp, 8.200.400.14 NMAC, 1/1/2019; A, 2/1/2020; A, 1/1/2022]
8.200.400.15 NMAC [RESERVED]
8.200.400.16 NMAC [RESERVED]
HISTORY OF 8.200.400 NMAC: The material in this part was derived from that previously filed with the State Records Center:
8 NMAC 4.MAD.400, Recipient Policies, Recipient Rights and Responsibilities, filed 12/30/1994.
History of Repealed Material:
8.200.400 NMAC, General Medicaid Eligibility, filed 6/15/2001 - Repealed effective 1/1/2014.
8.200.400 NMAC, General Medicaid Eligibility, filed 12/2/2013 - Repealed effective 10/1/2017.
8.200.400 NMAC, General Medicaid Eligibility, filed 9/14/2017 - Repealed effective 1/1/2019.
NMAC History:
8.200.400 NMAC, General
Medicaid Eligibility, filed 12/2/2013 was
replaced by 8.200.400 NMAC, General Medicaid Eligibility effective 10/1/2017.
8.200.400 NMAC, General
Medicaid Eligibility, filed 9/14/2017 was
replaced by 8.200.400 NMAC, General Medicaid Eligibility effective 1/1/2019.