TITLE 8                 SOCIAL SERVICES




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.

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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.

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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]