TITLE 8 SOCIAL SERVICES
CHAPTER 308 MANAGED CARE PROGRAM
PART 6 MANAGED
CARE ORGANIZATION (MCO) ENROLLMENT
8.308.6.1 ISSUING AGENCY: New Mexico Human Services Department (HSD).
[8.308.6.1 NMAC - Rp, 8.308.6.1 NMAC, 5/1/2018]
8.308.6.2 SCOPE: This rule applies to the general public.
[8.308.6.2 NMAC - Rp, 8.308.6.2 NMAC, 5/1/2018]
8.308.6.3 STATUTORY AUTHORITY: The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA 1978.
[8.308.6.3 NMAC - Rp, 8.308.6.3 NMAC, 5/1/2018]
8.308.6.4 DURATION: Permanent.
[8.308.6.4 NMAC - Rp, 8.308.6.4 NMAC, 5/1/2018]
8.308.6.5 EFFECTIVE DATE: May 1, 2018, unless a later date is cited at the end of a section.
[8.308.6.5 NMAC - Rp, 8.308.6.5 NMAC, 5/1/2018]
8.308.6.6 OBJECTIVE: The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance programs.
[8.308.6.6 NMAC - Rp, 8.308.6.6 NMAC, 5/1/2018]
8.308.6.7 DEFINITIONS: [RESERVED]
8.308.6.8 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.
[8.308.6.8 NMAC - Rp, 8.308.6.8 NMAC, 5/1/2018; A, 8/10/2021]
8.308.6.9 MANAGED CARE ELIGIBILITY:
A. General requirements: HSD determines eligibility for medicaid. An eligible recipient is required to participate in a HSD managed care program unless specifically excluded as listed below. Enrollment in a particular managed care organization (MCO) will be according to the eligible recipient’s selection of a MCO at the time of application for eligibility, or during other permitted selection periods, or as assigned by HSD, if the eligible recipient makes no selection.
(1) qualified medicare beneficiaries (QMB)-only recipients;
(2) specified low income medicare beneficiaries (SLIMB) only;
(3) qualified individuals;
(4) qualified disabled working individuals;
(5) refugees;
(6) participants in the program of all inclusive care for the elderly (PACE);
(7) children and adolescents in out-of-state foster care or adoption placements;
(8) family planning-only eligible recipients and;
(9) residents in an intermediate care
facility for individuals with intellectual disabilities (ICF/IID).
C. Native Americans may opt into managed care. If a Native American is dually eligible or in need of long-term care services, he or she is required to enroll in a MCO.
D. For those individuals who are not otherwise eligible for medicaid and who meet the financial and medical criteria established by HSD, HSD or its authorized agent may further determine eligibility for managed care enrollment through a waiver allocation process contingent upon available funding and enrollment capacity.
[8.308.6.9 NMAC - Rp, 8.308.6.9 NMAC, 5/1/2018; A, 1/1/2019; A, 8/10/2021]
8.308.6.10 SPECIAL SITUATIONS:
A. HSD newborn enrollment criteria.
(1) When a child is born to a member enrolled in a MCO, the hospital or other providers will complete a MAD form 313 (notification of birth) or its successor, prior to or at the time of discharge. HSD shall ensure that upon receipt of the MAD form 313 and upon completion of the eligibility process, the newborn is enrolled into his or her mother’s MCO. The newborn is eligible for a period of 13 months, starting with the month of his or her birth.
(2) When the newborn’s mother is covered by health insurance through the New Mexico health insurance exchange and the mother’s qualified health plan is also a HSD-contracted MCO, HSD will enroll the newborn into the mother’s MCO as of the month of his or her birth.
(3) When the newborn member’s mother is covered by health insurance through New Mexico health insurance exchange and the mother’s qualified health plan is not a HSD-contracted MCO, HSD shall auto-assign and enroll the newborn in a medicaid MCO as of the month of his or her birth.
(4) The newborn member’s parent or legal guardian will have three months from the first day of the month of birth to change the newborn’s MCO assignment. After the three-month period, the newborn’s MCO enrollment may only be changed for cause, as set forth in Paragraph (2) of Subsection H of 8.308.7.9 NMAC.
B. Community benefit eligibility:
(1) A member who meets a nursing facility (NF) level of care (LOC) and who does not reside in a NF will be eligible to receive home and community-based services and may choose to receive such services either through an agency-based or self-directed approach as outlined in 8.308.12 NMAC.
(2) Members who meet NFLOC and are eligible to receive community benefits must be enrolled in a centennial care MCO.
C. ICF/IID discharge: When an ICF/IID resident is discharged, enrollment into managed care will begin within two months following discharge.
[8.308.6.10 NMAC - Rp, 8.308.6.10 NMAC, 5/1/2018; A, 1/1/2019; A, 8/10/2021]
HISTORY OF 8.308.6
NMAC: [RESERVED]
History of Repealed
Material:
8.308.6 NMAC - Managed Care Program, Eligibility, filed 12/17/2013 Repealed effective 5/1/2018.