TITLE 8 SOCIAL
SERVICES
CHAPTER 248 MEDICAID ELIGIBILITY - MEDICARE DRUG
COVERAGE (CATEGORY 048)
PART 600 BENEFIT
DESCRIPTION
8.248.600.1 ISSUING AGENCY: New Mexico
Human Services Department.
[8.248.600.1
NMAC - N, 2-1-06]
8.248.600.2 SCOPE: The rule
applies to the general public.
[8.248.600.2
NMAC - N, 2-1-06]
8.248.600.3 STATUTORY AUTHORITY: The New Mexico
medicaid program is administered pursuant to
regulations promulgated by the federal department of health and human services
under Title XIX of the Social Security Act, as amended and by the state human
services department pursuant to state statute.
See NMSA 1978, 27-2-12 et.
seq. ( Repl. Pamp. 1991). The
legal basis for the low-income subsidy (LIS) program
is the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), Public Law 108-173.
[8.248.600.3
NMAC - N, 2-1-06]
8.248.600.4 DURATION: Permanent.
[8.248.600.4
NMAC - N, 2-1-06]
8.248.600.5 EFFECTIVE DATE: February 1,
2006, unless a later date is cited at the end of a section.
[8.248.600.5
NMAC - N, 2-1-06]
8.248.600.6 OBJECTIVE: The objective
of these regulations is to provide eligibility policy and procedures for the medicare part D - low income subsidy program.
[8.248.600.6
NMAC - N, 2-1-06]
8.248.600.7 DEFINITIONS: [RESERVED]
8.248.600.8 [RESERVED]
8.248.600.9 GENERAL BENEFIT DESCRIPTION: An individual
or couple who is determined eligible for the low
income subsidy (LIS) under part D of medicare, is eligible for financial assistance with the
monthly premium, the yearly deductible, the per-prescription co-payment, and
continuous coverage with no gap prior to reaching $3,600 in out-of-pocket
spending. The financial assistance may
be full or partial depending on the income, family size and resources of the
beneficiary.
[8.248.600.9
NMAC - N, 2-1-06]
8.248.600.10 BENEFIT DETERMINATION: Completed
applications must be acted upon and notice of approval, denial, or delay
sent out within forty-five (45) days of the date of application. The applicant will have time limits
explained, and be informed of the date by which the application should be
processed.
[8.248.600.10
NMAC - N, 2-1-06]
8.248.600.11 INITIAL BENEFITS: Eligibility is
always prospective and begins the month of application, but not earlier than
January 1, 2006. When an eligibility
determination is made, notice of the approval or denial is sent to the
individual. If the application is
denied, the notice shall include reason for denial and the applicant's right to
request a fair hearing.
[8.248.600.11
NMAC - N, 2-1-06]
8.248.600.12 ONGOING BENEFITS: The
applicant/recipient is responsible to report changes affecting eligibility
within ten (10) days of when the change took place. A re-determination of eligibility is made every
twelve (12) months. If a LIS recipient/applicant becomes eligible for certain medicaid categories; SSI, QMB, SLIMB, QI-1, WDI, IC, and HCBW, he will still
be eligible for LIS.
CMS will notify the beneficiary that he is now deemed eligible, because
of categorical relatedness and will take over the re-determination of
eligibility on a yearly basis. A change
notice will be sent to the LIS recipient. For the year 2006, all certification periods
will end December 31, 2006. Effective
January 1, 2007, the certification period will be twelve (12) months from the
month of application or re-certification.
[8.248.600.12
NMAC - N, 2-1-06]
8.248.600.13 RETROACTIVE BENEFIT COVERAGE: There is no
three (3) month retroactive LIS coverage under this
program. The subsidy is effective the
beginning of the month of application or January 1, 2006, whichever is later.
[8.248.600.13
NMAC - N, 2-1-06]
HISTORY OF 8.248.600 NMAC: [RESERVED]