TITLE 8               SOCIAL SERVICES

CHAPTER 230   MEDICAID ELIGIBILITY - FULL COVERAGE FOR PREGNANT WOMEN

PART 600            BENEFIT DESCRIPTION

 

8.230.600.1          ISSUING AGENCY:  New Mexico Human Services Department (HSD).

[8.230.600.1 NMAC - Rp, 8.230.600.1 NMAC, 1-1-14]

 

8.230.600.2          SCOPE:  The rule applies to the general public.

[8.230.600.2 NMAC - Rp, 8.230.600.2 NMAC, 1-1-14]

 

8.230.600.3          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 NMSA 1978, Section 27-1-12 et seq.

[8.230.600.3 NMAC - Rp, 8.230.600.3 NMAC, 1-1-14]

 

8.230.600.4          DURATION:  Permanent.

[8.230.600.4 NMAC - Rp, 8.230.600.4 NMAC, 1-1-14]

 

8.230.600.5          EFFECTIVE DATE:  January 1, 2014, unless a later date is cited at the end of a section.

[8.230.600.5 NMAC - Rp, 8.230.600.5 NMAC, 1-1-14]

 

8.230.600.6          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.

[8.230.600.6 NMAC - Rp, 8.230.600.6 NMAC, 1-1-14]

 

8.230.600.7          DEFINITIONS:  [RESERVED]

 

8.230.600.8          MISSION:  To reduce the impact of poverty on people living in New Mexico by providing support services that help families break the cycle of dependency on public assistance.

[8.230.600.8 NMAC - N, 1-1-14]

 

8.230.600.9          BENEFIT DESCRIPTION:  A medicaid eligible recipient under this category is eligible to receive the full range of medicaid covered services.  Applications received on or after January 1, 2014 will be evaluated for an Affordable Care Act category.

[8.230.600.9 NMAC - Rp, 8.230.600.9 NMAC, 1-1-14]

 

8.230.600.10        BENEFIT DETERMINATION:  Income support division (ISD) determines initial and ongoing eligibility.

                A.            A pregnant woman may have one presumptive eligibility determination made per pregnancy by an approved provider.  Presumptive eligibility determinations made after January 1, 2014, will be evaluated per Affordable Care Act rules.

                B.            An eligible recipient remains eligible throughout her pregnancy and for two months after the month of delivery or after the month in which the pregnancy terminated.

                C.            After the two-month postpartum period, medicaid coverage will be converted to Category 035 family planning services for 12 months.  Periodic eligibility reviews are not required during this period.

[8.230.600.10 NMAC - Rp, 8.230.600.10 NMAC, 1-1-14]

 

8.230.600.11        INITIAL BENEFITS:

                A.            Move during eligibility determination:  If an applicant moves to another county while the eligibility determination is pending, the county ISD office in which the application was originally registered shall transfer the case to the new responsible ISD office.

                B.            Delays in eligibility determination:  If an eligibility determination is not made within the time limit, the applicant is notified in writing of the reason for the delay.  This notice also informs the applicant of the right to request an administrative hearing.

[8.230.600.11 NMAC - Rp, 8.230.600.11 NMAC, 1-1-14]

 

8.230.600.12        [RESERVED]

 

8.230.600.13        RETROACTIVE BENEFIT COVERAGE:  Up to three months of retroactive medicaid coverage can be provided to applicants who have received medicaid-covered services during the retroactive period and would have met applicable eligibility criteria had they applied during the three months prior to the month of application [42 CFR Section 435.914].

                A.            Application for retroactive benefit coverage:  Applications for retroactive coverage can be submitted even after a pregnancy ends.  If the mother was not eligible for and receiving medicaid at the time of delivery or when the pregnancy terminated, retroactive coverage for Category 030 can only be extended through the month the pregnancy ended.  Application for retroactive medicaid can be made by indicating the existence of unpaid medical expenses in the three months prior to the month of application on the application form.  Applications for retroactive medicaid benefits must be made by 180 days from the date of application for assistance.

                B.            Approval requirements:  To establish retroactive eligibility, the caseworker must verify that all conditions of eligibility were met for each of the three retroactive months in which the applicant received medicaid-covered services.  Each month must be approved or denied on its own merit.  Retroactive eligibility can be approved on either the ISD eligibility system (for categories programmed on that system) or on the retroactive medicaid eligibility authorization MAD 333 form.

                C.            Notice:

                    (1)     Notice to applicant:  The applicant must be informed of the reason(s) for denial of eligibility for  any retroactive months.

                    (2)     Recipient responsibility to notify provider:  After the retroactive eligibility has been established, the caseworker must notify the recipient that he or she is responsible for informing all providers with outstanding bills of the retroactive eligibility determination.  If the recipient fails to inform all providers and furnish verification of eligibility which can be used for billing and the provider consequently does not submit the billing within the timeframes referenced in 8.302.2.11 NMAC the recipient is responsible for payment of the bill.

[8.230.600.13 NMAC - Rp, 8.230.600.13 NMAC, 1-1-14]

 

8.230.600.14        CHANGES IN ELIGIBILITY:  If a pregnant woman who is eligible for medicaid under Category 030 loses eligibility because of a change in family income, she automatically remains eligible for medicaid under Category 035, pregnancy related services or family planning services, without a new application.  The pregnancy related services only remain effective for the two months following the month in which the child is born or the pregnancy ends.  Coverage is limited to pregnancy related services only.  The family planning services for 12 months remain effective subsequent to the two month post-partum period.

[8.230.600.14 NMAC - Rp, 8.230.600.14 NMAC, 1-1-14]

 

8.230.600.15        PERIODIC REDETERMATIONS OF ELIGIBILITY:

                A.            A redetermination of eligibility is not required.

                B.            All changes that may affect eligibility must be reported within 10 calendar days from the date of the change as detailed in 8.200.430 NMAC.

[8.230.600.15 NMAC - N, 1-1-14]

 

HISTORY OF 8.230.600 NMAC:

Pre-NMAC History:  The material in this part was derived from that previously filed with the State Records Center.

ISD 290.1000, Medical Assistance for Woman and Children, filed 11-13-84.

ISD FA 830, Medical Assistance for Woman and Children and AFDC Related Groups, filed 2-10-88.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 8-11-88.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 9-8-88.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 9-30-88.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 12-1-88.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 3-31-89.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 6-8-89.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 12-28-89.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 12-29-89.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 3-1-91.

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 6-5-92.

 

History of Repealed Material:

MAD Rule 830, Medical Assistance for Women and Children and AFDC - Related Groups, filed 6-5-92 - Repealed effective 2-1-95.

8.230.600 NMAC, Benefit Description, filed 6-13-12 - Repealed effective 1-1-14.