TITLE 8                 SOCIAL SERVICES




8.300.1.1               ISSUING AGENCY:  New Mexico Human Services Department.

[2/1/95; 8.300.1.1 NMAC - Rn, 8 NMAC 4.MAD.000.1, 5/1/04]


8.300.1.2               SCOPE:  The rule applies to the general public.

[2/1/95; 8.300.1.2 NMAC - Rn, 8 NMAC 4.MAD.000.2, 5/1/04]


8.300.1.3               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 state statute.  See Section 27-2-12 et seq. NMSA 1978 (Repl. Pamp. 1991).

[2/1/95; 8.300.1.3 NMAC - Rn, 8 NMAC 4.MAD.000.3, 5/1/04; A, 9/15/08]


8.300.1.4               DURATION:  Permanent

[2/1/95; 8.300.1.4 NMAC - Rn, 8 NMAC 4.MAD.000.4, 5/1/04]


8.300.1.5               EFFECTIVE DATE:  February 1, 1995, unless a later date is cited at the end of a section.

[2/1/95; 8.300.1.5 NMAC - Rn, 8 NMAC 4.MAD.000.5, 5/1/04; A, 9/15/08]


8.300.1.6               OBJECTIVE:  The objective of these rules is to provide policies for the service portion of the New Mexico medical assistance programs.

[2/1/95; 8.300.1.6 NMAC - Rn, 8 NMAC 4.MAD.000.6, 5/1/04; A, 9/15/08]


8.300.1.7               DEFINITIONS:  [RESERVED]


8.300.1.8               MISSION STATEMENT:  The mission of the New Mexico medical assistance division (MAD) is to maximize the health status of eligible recipients by furnishing payment for quality health services at levels comparable to private health plans.

[2/1/95; 8.300.1.8 NMAC - Rn, 8 NMAC 4.MAD.002, 5/1/04; A, 9/15/08]


8.300.1.9               GENERAL PROGRAM DESCRIPTION:  Human services department (HSD), through MAD, is responsible for the administration of the medicaid program and other health care programs.  This joint federal and state program provides payment for medically necessary health services furnished to eligible recipients.

[2/1/95; 8.300.1.9 NMAC - Rn, 8 NMAC 4.MAD.010, 5/1/04; A, 9/15/08]


8.300.1.10             RELATIONSHIP TO MEDICARE:  MAD covers medically necessary health services furnished to eligible recipients who meet specific income, resource and eligibility standards.  Medicare is a federal program which offers health insurance coverage to eligible recipients 65 years of age or older, to those who have received disability benefits for 24 consecutive months, to those who have end stage renal disease, and to other eligible recipients, as specified by other provisions of the Social Security Act.

                A.            The state of New Mexico has entered into an agreement with the social security administration to pay medicaid eligible recipient premiums for medicare part B, and under some circumstances, medicare part A premiums.

                B.            After medicare has made payment for services, the medicaid program pays for the medicare co-insurance and deductible amounts for all eligible medicaid recipients subject to the following medicaid reimbursement limitations.

                    (1)     Medicaid payment for the co-insurance and deductible is limited such that the payment from medicare, plus the amount allowed by medicaid for the co-insurance and deductible, shall not exceed the medicaid allowed amount for the service.  When the medicare payment exceeds the amount that medicaid would have allowed for the service, no payment is made for the co-insurance or deductible.  The claim is considered paid in full.  The provider may not collect any remaining portion of the medicare co-insurance or deductible from the eligible recipient or their personal representative.  For services for which medicare part B applies a 50 percent co-insurance rate, medicare co-insurance and deductible amounts may be paid at an amount that allows the provider to receive more than medicaid allowed amount, not to exceed a percentage determined by HSD.

                    (2)     The medicaid program will pay toward the medicare co-insurance and deductible to the extent that the amount paid by medicare and the allowed medicare co-insurance and deductible together do not exceed the medicaid allowed amount.  The medicaid program will pay the medicare co-insurance and deductible when the medicaid program does not have a specific amount allowed for the service.

[2/1/95; 8.300.1.10 NMAC - Rn, 8 NMAC 4.MAD.011 & A, 5/1/04; A, 9/15/08]



Pre-NMAC History:  The material in this part was derived from that previously filed with the State Records Center:

SP-001.0300, Section 1, Single State Agency Organization Statewide Operations, filed 1/15/81.

SP-003.0200, Section 3, Services: General Provisions Coordination of Medicaid with Medicare Part B, filed 1/23/81.

SP-004.0100, Section 4, General Program Administration Methods of Administration, filed 1/23/81.

SP-004.0600, Section 4, General Program Administration Reports, filed 1/23/81.

SP-003.0201, Coordination of Title XIX With Part B of Title XVIII, filed 2/25/81.

SP-004.1000, Section 4, General Program Administration Free Choice of Providers, filed 3/3/81.

SP-004.1200, Section 4, General Program Administration Consultation to Medical Facilities, filed 3/3/81.

SP-004.1500, Section 4, General Program Administration Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Diseases, filed 3/5/81.

SP-004.1800, Section 4, General Program Administration Cost Sharing and Similar Charges, filed 3/5/81.

SP-004.2500, Section 4, General Program Administration Program for Licensing Administrators of Nursing Homes, filed 3/5/81.

SP-005.0100, Section 5, Personnel Administration Standards of Personnel Administration, filed 3/5/81.

SP-005.0300, Section 5, Personnel Administration Training Programs, Subprofessional and Volunteer Programs, filed 3/5/81.

SP-007.0100, Section 7, General Provisions Plan Amendments, filed 3/5/81.

SP-001.0201, Section 1, Single State Agency Organization, Organization and Function of State Agency, filed 3/11/81.


History of Repealed Material:  [RESERVED]