TITLE 8 SOCIAL SERVICES
CHAPTER
234 MEDICAID ELIGIBILITY - SSI
INELIGIBILITY - DUE TO INCOME OR RESOURCES FROM AN ALIEN SPONSOR
PART 600 BENEFIT DESCRIPTION
8.234.600.1 ISSUING AGENCY:
New Mexico Human Services Department (HSD).
[8.234.600.1
NMAC - Rp, 8.234.600.1 NMAC, 1-1-14]
8.234.600.2 SCOPE: The
rule applies to the general public.
[8.234.600.2
NMAC - Rp, 8.234.600.2 NMAC, 1-1-14]
8.234.600.3 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.
[8.234.600.3
NMAC - Rp, 8.234.600.3 NMAC, 1-1-14]
8.234.600.4 DURATION:
Permanent.
[8.234.600.4
NMAC - Rp, 8.234.600.4 NMAC, 1-1-14]
8.234.600.5 EFFECTIVE DATE:
January 1, 2014, unless a later date is cited at the end of a section.
[8.234.600.5
NMAC - Rp, 8.234.600.5 NMAC, 1-1-14]
8.234.600.6 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 Chapter 8.100 NMAC, General Provisions for Public Assistance Programs.
[8.234.600.6
NMAC - Rp, 8.234.600.6 NMAC, 1-1-14]
8.234.600.7 DEFINITIONS:
[RESERVED]
8.234.600.8 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.
[8.234.600.8 NMAC - N, 1-1-14]
8.234.600.9 BENEFIT DESCRIPTION:
Under the eligibility Category 034, an eligible recipient receives the
full range of medicaid covered services.
[8.234.600.9
NMAC - Rp, 8.234.600.9 NMAC, 1-1-14]
8.234.600.10 BENEFIT
DETERMINATION:
A. Income support division (ISD) determines initial and
ongoing eligibility.
B. Up to three months of retroactive medicaid
coverage is provided to an applicant who has received a medicaid
covered service during the retroactive period and who would have met applicable
eligibility criteria had they applied earlier.
Eligibility for each retroactive month is determined separately. An application for retroactive medicaid enrollment must be made within 180 calendar days
from the date of the medicaid application.
[8.234.600.10
NMAC - Rp, 8.234.600.10 NMAC, 1-1-14]
8.234.600.11 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 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 or
re-determining recipient of the right to request an administrative hearing.
[8.234.600.11
NMAC - Rp, 8.234.600.11 NMAC, 1-1-14]
8.234.600.12 PERIODIC REDETERMINATIONS OF
ELIGIBILITY:
A. A
re-determination of eligibility is made every 12 months.
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.
[8.234.600.12
NMAC - Rp, 8.234.600.12 NMAC, 1-1-14]
8.234.600.13 SSI RETROACTIVE BENEFIT COVERAGE:
Up to three months of retroactive medicaid
coverage can be furnished 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 435.914].
A. Application
for retroactive benefit coverage:
Application for retroactive medicaid can be
made by checking “yes” in the “application for retroactive medicaid
payments” box on the application or re-determination of eligibility for medical
assistance (MAD 381) form or by checking “yes” to the question “does anyone in
your household have unpaid medical expenses in the last three months?” on the
application for assistance (ISD 100 S) form.
Applications for retroactive supplemental security income (SSI) medicaid benefits for recipients of SSI must be made by 180
days from the date of approval for SSI.
Medicaid covered services which were furnished more than two years prior
to approval are not covered.
B. Approval
requirements: To establish
retroactive eligibility, the income support specialist (ISS) must verify that
all conditions of eligibility were met for each of the three retroactive months
and that the applicant received medicaid covered
services. Eligibility for each month is
approved or denied on its own merits.
(1) Applicable benefit rate: The federal benefit rate (FBR) in effect
during the retroactive months based on the applicant’s living arrangements is
applicable for retroactive medicaid eligibility
determinations. See
8.200.520.10 NMAC. If the
applicant’s countable income in a given month exceed
the applicable FBR, the applicant is not eligible for retroactive medicaid for that month.
If the countable income is less that the FBR, the applicant is eligible
on the factor of income for that month.
A separate determination must be made for each of the three months in the
retroactive period.
(2) Disability determination required: If a determination is needed of the date of
onset of blindness or disability, the ISS must send a referral to disability
determination services (ISD 305) to the disability determination unit.
C. Notice:
(1) Notice to applicant: The applicant must be informed if any of the
retroactive months are denied.
(2) Recipient responsibility to notify
provider: After the retroactive
eligibility has been established, the ISS 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 does not inform all providers and furnish verification
of eligibility which can be used for billing and the provider consequently does
not submit the billing within 120 days from the date of approval of retroactive
coverage, the recipient is responsible for payment of the bill.
[8.234.600.13
NMAC - Rp, 8.234.600.13 NMAC, 1-1-14]
HISTORY
OF 8.234.600 NMAC:
History of Repealed Material:
8.234.600
NMAC, Benefit Description, filed 9-3-13 - Repealed effective 1-1-14.