TITLE 8 SOCIAL SERVICES

CHAPTER 235 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY - PREGNANCY SERVICES

PART 600 BENEFIT DESCRIPTION

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

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8.235.600.2 SCOPE: The rule applies to the general public.

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8.235.600.3 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.

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8.235.600.4 DURATION: Permanent.

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

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8.235.600.6 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.

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8.235.600.7 DEFINITIONS: [RESERVED]

8.235.600.8 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.

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8.235.600.9 GENERAL BENEFIT DESCRIPTION: This category provides pregnancy-related medicaid services for women and family planning and related services for both men and women whose income is below 185 percent of the federal income poverty level (FPL). There is no resource test for this category. Applications received on or after January 1, 2014 are evaluated for an Affordable Care Act category.

A. Pregnancy-related services only: Under medicaid eligibility Category 035, the pregnant eligible recipient only receives services related to her pregnancy and for diagnosis and treatment of conditions which could complicate or adversely impact the woman’s pregnancy, the fetus’s health, or the child’s delivery. Coverage extends throughout the pregnancy and for a two-month post-partum period after the month of delivery or after the month in which the pregnancy terminates.

B. Family planning services: Under medicaid eligibility Category 035, a non-pregnant eligible recipient (including a male) only receives services, consultations, and supplies related to birth control, pregnancy prevention and family planning related services which are prescribed and furnished by physicians, hospitals, clinics, pharmacies, and other medicaid providers.

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8.235.600.10 BENEFIT DETERMINATION: Income support division (ISD) determines initial and ongoing eligibility. Refer to 8.100 NMAC, 8.200 NMAC, 8.235.400 NMAC and 8.235.500 NMAC.

A. A pregnant woman may have one presumptive eligibility determination made by a medicaid approved provider.

B. Up to three months of retroactive medicaid coverage is provided to an applicant who has received medicaid services during the retroactive period and who would have met applicable eligibility criteria had she applied earlier. At the earliest point that retroactive eligibility is determined, eligibility extends throughout the pregnancy and the two-month postpartum period. Application for retroactive medicaid enrollment must be made within 180 calendar days from the date of the medicaid application.

C. An eligible woman recipient remains eligible throughout her pregnancy and for two months after the month of delivery or after the month in which the pregnancy terminates. Changes in household income do not affect her eligibility during this period. After the two-month postpartum period, medicaid pregnancy-related services will be converted to medicaid family planning services. Periodic eligibility reviews are not required during this period.

D. Family planning services continue for 12 months. Changes in household income do not affect eligibility during this period.

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8.235.600.11 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 transfers 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 eligible recipient of the right to request an administrative hearing.

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8.235.600.12 ONGOING BENEFITS:

A. A redetermination of eligibility is not required during a pregnancy, the two-month postpartum period or through the first 12 months of the family planning period. For continued family planning services, a redetermination 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.

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8.235.600.13 RETROACTIVE BENEFIT COVERAGE: Refer to 8.235.600.10 NMAC.

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8.235.600.14 REPORTING REQUIREMENTS: Refer to 8.200.430.19 NMAC.

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8.235.600.15 CHANGES IN ELIGIBILITY DUE TO INCOME:

A. Pregnancy-related services only: A recipient who is pregnant and who loses eligibility solely because of a change in family income remains eligible under Category 035 throughout the remainder of the pregnancy and the two months following the month the pregnancy ends. This provision applies even if the family income exceeds the federal poverty income guidelines.

B. Family planning services: A man or woman who is receiving family planning and related services only under medicaid will not lose eligibility at any time during the 12-month certification period, due to an increase in family income which exceeds the federal poverty income limit.

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HISTORY OF 8.235.600 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.

8.235.600 NMAC, Benefit Description, filed 5-13-04 - Repealed effective 1-1-14.