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 Health Care Authority.

[8.248.600.1 NMAC - Rp 8.248.600.1 NMAC, 7/1/2024]

 

8.248.600.2          SCOPE:  The rule applies to the general public.

[8.248.600.2 NMAC - Rp 8.248.600.2NMAC, 7/1/2024]

 

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 health care authority pursuant to state statute.  See 27-2-12 et. seq.NMSA 1978 ( 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.  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.

[8.248.600.3 NMAC - Rp 8.248.600.3NMAC, 7/1/2024]

 

8.248.600.4          DURATION:  Permanent.

[8.248.600.4 NMAC - Rp 8.248.600.4NMAC, 7/1/2024]

 

8.248.600.5          EFFECTIVE DATE:  July 1, 2024, unless a later date is cited at the end of a section.

[8.248.600.5 NMAC - Rp 8.248.600.5NMAC, 7/1/2024]

 

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 - Rp 8.248.600.6NMAC, 7/1/2024]

 

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 - Rp 8.248.600.9NMAC, 7/1/2024]

 

8.248.600.10       BENEFIT DETERMINATION:  Completed applications must be acted upon and notice of approval, denial, or delay sent out within 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 - Rp 8.248.600.10NMAC, 7/1/2024]

 

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 - Rp 8.248.600.11NMAC, 7/1/2024]

 

8.248.600.12       ONGOING BENEFITS:  The applicant/recipient is responsible to report changes affecting eligibility within 10 days of when the change took place.  A re-determination of eligibility is made every 12 months.  If a LIS recipient/applicant becomes eligible for certain medicaid categories; SSI, QMB, SLIMB, QI-1, WDI, IC, and HCBW, they will still be eligible for LIS.  CMS will notify the beneficiary that they are 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 12 months from the month of application or re-certification.

[8.248.600.12 NMAC - Rp 8.248.600.12NMAC, 7/1/2024]

 

8.248.600.13       RETROACTIVE BENEFIT COVERAGE:  There is no three 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 - Rp 8.248.600.13NMAC, 7/1/2024]

 

HISTORY OF 8.248.600 NMAC:  [RESERVED]

 

History of Repealed Material:  8.248.600 NMAC - Benefit Description (filed 1/13/2006) Repealed effective 7/1/2024.

 

Other:  8.248.600 NMAC - Benefit Description (filed 1/13/2006) Replaced by 8.248.600 NMAC - Benefit Description effective 7/1/2024.