TITLE 8 SOCIAL SERVICES
CHAPTER 285 MEDICAID ELIGIBILITY - EMERGENCY MEDICAL
SERVICES FOR
NON-CITIZENS
PART 600 BENEFIT DESCRIPTION
8.285.600.1 ISSUING AGENCY: New
Mexico Human Services Department.
[2/1/1995;
8.285.600.1 NMAC - Rn, 8 NMAC 4.ESA.000.1, 12/1/2008]
8.285.600.2 SCOPE: The
rule applies to the general public.
[2/1/1995;
8.285.600.2 NMAC - Rn, 8 NMAC 4.ESA.000.2, 12/1/2008]
8.285.600.3 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 Section 27-2-12 et seq. NMSA 1978 (Repl. Pamp.
1991).
[2/1/1995;
8.285.600.3 NMAC - Rn, 8 NMAC 4.ESA.000.3, 12/1/2008]
8.285.600.4 DURATION:
Permanent.
[2/1/1995;
8.285.600.4 NMAC - Rn, 8 NMAC 4.ESA.000.4, 12/1/2008]
8.285.600.5 EFFECTIVE DATE:
February 1, 1995, unless a later date is cited at the end of a section.
[2/1/1995;
8.285.600.5 NMAC - Rn, 8 NMAC 4.ESA.000.5 & A, 12/1/2008]
8.285.600.6 OBJECTIVE: The
objective of these regulations is to provide eligibility policy and procedures
for the medicaid program.
[2/1/1995; 8.285.600.6
NMAC - Rn, 8 NMAC 4.ESA.000.6, 12/1/2008]
8.285.600.7 DEFINITIONS: [RESERVED]
8.285.600.8 MISSION STATEMENT: To transform lives. Working with our partners, we design and
deliver innovative, high quality health and human services that improve the
security and promote independence for New Mexicans in their communities.
[8.285.600.8 NMAC -
A, 5/1/2020]
8.285.600.9 BENEFIT DESCRIPTION: An
applicant/recipient who is eligible for medicaid under this category is
eligible for emergency services coverage only for the duration of the
emergency.
[2/1/1995;
8.285.600.9 NMAC - Rn, 8 NMAC 4.ESA.600 & A, 12/1/2008]
8.285.600.10 BENEFIT DETERMINATION:
A. Subsequent to the receipt of emergency services, an
applicant must apply through the local county income support division (ISD)
office. The application must be filed at
the ISD office no later than the last day of the third month following the
month the presumed emergency services were received.
B. Documentation requirements: The applicant must bring a completed
emergency medical services for non-citizens (EMSNC) referral for eligibility
determination form (MAD 308) to the ISD office for the financial eligibility
determination. The emergency services
provider must complete the referral form.
C. Financial documents: The applicant must provide all necessary
documentation to prove that they meet all financial and non-financial
eligibility standards. Medical providers
cannot submit eligibility applications on behalf of the applicant. The applicant is financially responsible for
any services not covered by medicaid. A
completed and signed application form must be submitted for each request for EMSNC.
[2/1/1995; 4/30/1998;
8.285.600.10 NMAC - Rn, 8 NMAC 4.ESA.620 & A, 12/1/2008; A, 5/1/2020; A, 1/1/2022]
8.285.600.11 INITIAL BENEFITS:
Applications for medicaid must be acted on within 45 days of the date of
application.
A. If an applicant is eligible for medicaid, the individual
is sent a notice of case action (NOCA) form. The approval of financial
eligibility is not a guarantee that medicaid will pay for the services. The NOCA form also serves as notice of case
closure, since medicaid covers only emergency services received during the
specified term of the emergency. The
provider is sent the decision for emergency medical services for non-citizens
(EMSNC) application (MAD 778) form. The
provider must use the MAD 778 form to submit claims to the medicaid utilization
review contractor for emergency review.
B. If an applicant is ineligible for medicaid or a decision
on the application is delayed beyond the 45 day time limit, the individual is
sent a NOCA form regarding the application for EMSNC. The NOCA
form explains the reason for denial or delay and informs the applicant of their
right to an administrative hearing. If
the application is denied, the applicant must notify providers of the denial.
C. The applicant is
responsible for payment for the medical services if they fail to apply promptly
for coverage, verify eligibility for coverage, or notify the provider of the
approval or denial of the application.
[2/1/1995; 4/30/1998;
8.285.600.11 NMAC - Rn, 8 NMAC 4.ESA.623 & A, 12/1/2008; A, 5/1/2020; A, 1/1/2022]
8.285.600.12 ONGOING BENEFITS: No
periodic review is necessary, since this category does not result in continuous
eligibility. The eligibility for the
specific period will only cover the bona fide emergency services. A medicaid card is not issued. No separate notice of case closure is
necessary. Notice of approval serves as
notice of closure as it indicates the specific period of eligibility. Medicaid covers emergency services only for
the duration of the emergency, as determined by medicaid utilization review
contractor.
[2/1/1995; 4/30/1998;
8.285.600.12 NMAC - Rn, 8 NMAC 4.ESA.624 & A, 12/1/2008]
8.285.600.13 RETROACTIVE COVERAGE: There
is no retroactive coverage for this category.
[2/1/1995;
8.285.600.13 NMAC - Rn, 8 NMAC 4.ESA.625 & A, 12/1/2008]
HISTORY OF
8.285.600 NMAC: [RESERVED]