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]