reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.12 - ESTABLISHMENT OF PROSPECTIVE PER-DIEM RATES

Current through Register Vol. 35, No. 13, July 16, 2024
Prospective per diem rates will be established as follows
				  and will be the lower of the amount calculated using the following formulas, or
				  the ceiling:
A.
Base year:
Rebasing of the prospective per diem rate will take place every three years.
				Therefore, the operating years under this plan will be known as year one, year
				two and year three. Because rebasing is done every three years, operating year
				four will again become year one, etc. Cost incurred, reported, audited or desk
				reviewed for the provider's last fiscal year which falls in the calendar year
				prior to year one will be used to rebase the prospective per-diem rate.
				Rebasing of costs in excess of one hundred and ten percent of the previous
				year's audited cost per diem times the index (as described further on in these
				regulations) will not be recognized for calculation of the base year costs. For
				implementation year one (effective July 1, 1984) the base year is the
				provider's last available audited cost report prior to January 1, 1984.
				Rebasing will occur out of cycle for rates effective January 1, 1996, using the
				provider's FYE 1994 audited cost reports. The rate period January 1, 1996,
				through June 30, 1996, will be considered year one. The rate period July 1,
				1996, through June 30, 1997, will be considered year two, and the rate period
				July 1, 1997, through June 30, 1998, will be considered year three. The
				rebasing cycle will resume for rates effective July 1, 1998, and continue as
				described in the first paragraph of this section. Pursuant to budget
				availability, any changes to reimbursement, including the decision to rebase
				rates will be at the department's discretion.
B.
Inflation factor
to recognize
				economic conditions and trends during the time period covered by the provider's
				prospective per diem rate:
(1) Pursuant to
				budget availability and at the department's discretion, an inflation factor may
				be used to recognize economic conditions and trends. A notice will be sent out
				every July informing each provider that a:
(a)
				MBI will or will not be authorized; and
(b) the percentage increase if the MBI is
				authorized.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.14 - IMPUTED OCCUPANCY

Current through Register Vol. 35, No. 13, July 16, 2024
In order to insure that the medicaid program does not pay
				  for costs associated with unnecessary beds as evidenced by under-utilization,
				  allowable facility costs will be calculated by imputing a ninety percent
				  occupancy rate. This provision will apply to:
A. any new facility certified for
				participation in the medicaid program on or after January 1, 1988;
B. existing facilities, if the number of
				licensed or certified beds increases on or after January 1, 1988. In such
				cases, occupancy will be imputed for all beds;
C. replacement facilities, certified for
				participation in the medicaid program on or after January 1, 1988, if the
				replacement facility contains a higher number of licensed or certified beds
				than the facility being replaced;
D. any replaced facility which re-enters the
				medicaid program on or after January 1, 1988, either under the same ownership
				or different ownership;
E. any
				closed facility which re-enters the medicaid program on or after January 1,
				1988;
F. facility costs will be
				adjusted and the resulting rate change will become effective when any of the
				above occurs; providers operating such facilities shall submit appropriate
				information regarding facility costs so that the rate adjustment can be
				computed.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.15 - ADJUSTMENTS TO BASE YEAR COSTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Since rebasing of the prospective per diem rate will take place every three
				years, the department recognizes that certain circumstances may warrant an
				adjustment to the base rate. Therefore, the provider may request such an
				adjustment for the following reasons:
(1)
				additional costs incurred to meet new requirements imposed by government
				regulatory agencies, taxation authorities, or applicable law (e.g. minimum
				staffing requirements, social security taxation of 501 (c)(3) corporations,
				minimum wage change, property tax increases, etc.);
(2) additional costs incurred as a result of
				uninsurable losses from catastrophic occurrences; and
(3) additional costs of approved expansion,
				remodeling or purchase of equipment;
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.16 - IMPLEMENTATION OF NURSING HOME REFORM REQUIREMENTS EFFECTIVE OCTOBER 1, 1990

Current through Register Vol. 35, No. 13, July 16, 2024
As mandated by Section 1919 of the Social Security Act, the
				  following changes are made effective October 1, 1990:
A.
Elimination of SNF/ICF
				Distinction:
Effective October 1, 1990, the SNF and ICF distinctions
				will be eliminated and all participating providers will become NFs. In order to
				account for the change the following will be implemented:
(1) Two levels of NF services will exist,
				representing the care needs of the respective recipients: High NF; Low
				NF.
(2) A high NF rate and a low NF
				rate will be established for each provider.
(3) For existing SNFs, the High NF rate will
				be the provider's SNF rate in effect on September 30, 1990.
(4) For existing SNFs with no existing ICF
				rate, the low NF rate will be the provider's SNF rate in effect on September
				30, 1990, minus an amount equal to the statewide mean differential of the
				operating component of current SNF/ICF rates.
(5) For existing ICFs, the low NF rate will
				be the provider's ICF rate in effect on September 30, 1990.
(6) For existing ICFs with no existing SNF
				rate, the high NF rate will be the provider's ICF rate in effect on September
				30, 1990, plus an amount equal to the statewide mean differential of the
				operating component of current SNF/ICF rates.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.17 - PAYMENT OF RESERVE BED DAYS

Current through Register Vol. 35, No. 13, July 16, 2024
When medicaid payment is made to reserve a bed while the
				  recipient is absent from the facility, the reserve bed day payment shall be in
				  an amount equal to fifty percent of the regular payment rate.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.18 - RECONSIDERATION PROCEDURES FOR LONG TERM CARE DETERMINATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A provider who is dissatisfied with the
				base year rate determination or the final settlement (in the case of a change
				in ownership) may request a reconsideration of the determination by addressing
				a request for reconsideration to: director, medical assistance division, human
				services department, P.O. Box 2348, Santa Fe, New Mexico 87504-2348.
B. The filing of a request for
				reconsideration will not effect the imposition of the determination.
C. A request for reconsideration, to be
				timely, must be filed with or received by the medical assistance division
				director no later than 30 days after the date of the determination notice to
				the provider.
D. The written
				request for reconsideration must identify each point on which it takes issue
				with the audit agent and must include all documentation, citation of authority,
				and argument on which the request is based. Any point not raised in the
				original filed request may not be raised later.
E. The medical assistance division will
				submit copies of the request and supporting material to the audit agent. A copy
				of the transmittal letter to the audit agent will be sent to the provider. A
				written response from the audit agent must be filed with or received by the
				medical assistance division no later than 30 days after the date of the
				transmittal letter.
F. The medical
				assistance division will submit copies of the audit agent's response and
				supporting material to the provider. A copy of the transmittal letter to the
				provider will be sent to the audit agent. Both parties may then come up with
				additional submittals on the point(s) at issue. Such follow-up submittals must
				be filed with or received by the medical assistance division no later than 15
				days after the date of the transmittal letter to the provider.
G. The request for reconsideration and
				supporting materials, the response and supporting materials, and any additional
				submittal will be delivered by the medical assistance division director to the
				secretary, or his/her designee, within 5 days after the closing date for final
				submittals.
H. The secretary, or
				his/her designee, may secure all information and call on all expertise he/she
				believes necessary to decide the issues.
I. The secretary, or his/her designee, will
				make a determination on each point at issue, with written findings and will
				mail a copy of the determinations to each party within 30 days of the delivery
				of the material to him. The secretary's determinations on appeals will be made
				in accordance with the applicable provisions of the plan. The secretary's
				decision will be final and any changes to the original determination will be
				implemented pursuant to that decision.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.19 - PUBLIC DISCLOSURE OF COST REPORTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Providers' cost reports submitted by
				participating providers as a basis for reimbursement as required by law are
				available to the public upon receipt of a written request to the medical
				assistance division. Information thus disclosed is limited to cost report
				documents required by social security administration regulations and, in the
				case of a settled cost report, the notice of program settlement.
B. The request must identify the provider and
				the specific report(s) requested.
C. The provider whose report has been
				requested will be notified by the medical assistance division that its cost
				report has been requested, and by whom. The provider shall have 10 days in
				which to comment to the requester before the cost report is released.
D. The cost for copying will be charged to
				the requester.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.20 - SEVERABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If any provision of this regulation is held to be invalid,
				  the remainder of the regulations shall not be affected
				  thereby.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Health Care Authority, Medical Assistance
				  Division.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
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 Section 27-2-12 et. seq. NMSA
				  1978 (Repl. Pamp. 1991). 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.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to govern the service
				  portion of the New Mexico medicaid and medical assistance programs. These
				  policies describe eligible providers, covered services, noncovered services,
				  utilization review, and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of HCA/MAD program eligible individuals
				  by furnishing payment for quality health services at levels comparable to
				  private health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.9 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program (medicaid) pays for medically
				  necessary health services furnished to recipients, including services furnished
				  by intermediate care facilities for the mentally retarded
				  42 CFR
				  440.150. This section describes eligible
				  providers, covered services, service restrictions, personal fund accounts, and
				  general reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				agreements by New Mexico medical assistance division (MAD), intermediate care
				facilities for the mentally retarded (ICF-MR) which meet the following
				conditions for participation are eligible to be reimbursed for providing
				services to eligible medicaid recipients:
(1)
				the ICF-MR must be licensed and certified by the division of health
				improvement, health facility licensing and certification bureau of the HCA to
				meet the intermediate care facility requirements. See 42 CFR 483 Subpart
				I;
(2) the ICF-MR must comply with
				8.313.2.17 NMAC,
Recipient
				Personal Fund Accounts
; and
(3) the ICF-MR must participate in the MAD
				utilization review process and must agree to operate in accordance with all
				policies and procedures of that system, including the performance of discharge
				planning.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.11 - APPEALS PROCESS FOR DENIAL, TERMINATION OR NONRENEWAL OF PARTICIPATION

Current through Register Vol. 35, No. 13, July 16, 2024
See Section MAD-967.5,
Appeals for Denial,
				  Termination, or Non-Renewal of Provider
				  Participation
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.12 - SANCTIONS AND PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
See Section MAD-967,
Sanctions for
				  Non-Compliance
and Section MAD-968,
Intermediate
				  Remedies
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.13 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Providers who furnish services to HCA/MAD program eligible recipients must
				comply with all specified HCA/ MAD participation requirements. See Section
				MAD-701,
General Provider Policies
.
B. Providers must verify that individuals are
				eligible for medicaid at the time services are furnished and determine if
				medicaid recipients have other health insurance.
C. Providers must maintain all medical or
				business records as necessary to fully disclose the type and extent of services
				provided to recipients. See Section MAD-701,
General Provider
				Policies
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.14 - REQUIRED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid does not reimburse ICFs-MR for furnishing services,
				  unless they provide at least the following, see
				  42 CFR
				  483.440(a):
A. room and board;
B. continuous active treatment program,
				including aggressive, consistent implementation of a program of specialized and
				generic training, treatment, health services and related services that are
				directed towards the following:
(1)
				acquisition of the behaviors necessary for the recipient to function with as
				much self determination and independence as possible; and
(2) prevention or deceleration of regression
				or loss of current functional status.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.15 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers the costs of ICF-MR services identified as
				  allowable. See 8.313.3 NMAC,
Cost Related Reimbursement of Intermediate
				  Care Facilities for the Mentally Retarded
, Section III.G. Pharmacy
				  services furnished in the ICF-MR are reimbursed separately and are subject to
				  specific requirements. See Section MAD-753,
Pharmacy
				  Services
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.16 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Medicaid does not cover the costs of ICF-MR services that are not allowable.
				See 8.313.3 NMAC,
Cost Related Reimbursement of Intermediate Care
				Facilities for the Mentally Retarded
.
B. Medicaid does not pay for residents with a
				primary diagnosis of mental retardation who are receiving care in a general
				nursing facility setting. Coverage of these residents is included only when
				they are residing in an ICF-MR facility or in a nursing facility when they have
				a medical condition which by and of itself would justify NF care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.17 - RECIPIENT PERSONAL FUND ACCOUNTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. As a condition for participation in
				medicaid, each ICF-MR must establish and maintain an acceptable system of
				accounting for a resident's personal funds when a Title XIX (medicaid)
				recipient requests that their personal funds be cared for by the facility. See
				42 CFR
				483.10(c).
(1) Requests for ICFs-MR to care or not care
				for a resident's funds must be made in writing and secured by a request to
				handle recipient's fund form or a letter signed by the resident or their
				representative. The form or letter is retained in the recipient's file at the
				facility.
(2) A recipient's
				personal fund consists of a monthly maintenance allowance established by MAD.
				If the resident receives any income in excess of this allowance, the excess is
				applied to the cost of the resident's medical care at the facility. This excess
				is reported as a medical care credit to the facility by the local county income
				support division (ISD) office, when applicable.
(3) All facilities must have procedures on
				the handling of medicaid residents' funds. These procedures must not allow the
				facility to commingle medicaid residents' funds with facility funds.
(4) Facilities should use these medicaid
				guidelines to develop procedures for handling resident funds.
(5) Residents have the right to manage their
				financial affairs and no facility can require residents to deposit their
				personal funds with the facility.
(6) Facilities must purchase a surety bond or
				provide self-insurance to ensure the security of all personal funds deposited
				with the facility.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.18 - LEVEL OF CARE DETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
Medical necessity, level of care or length of stay
				  determinations, and on-site review activities are carried out in accordance
				  with the MAD utilization review policy and procedures, authorized under Title
				  XIX of the Social Security Act. See 8.350.3 NMAC,
Abstract Submission
				  for Level of Care Determinations
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.19 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All HCA/MAD program services are subject to utilization
				  review for medical necessity and program compliance. Reviews can be performed
				  before services are furnished, after services are furnished and before payment
				  is made, or after payment is made. See 8.302.5 NMAC,
Prior
				  Authorization and Utilization Review
. Once enrolled, providers receive
				  instructions and documentation forms necessary for prior authorization and
				  claims processing.
A. Prior
				authorization: Certain procedures or services can require prior authorization
				from MAD or its designee. Services for which prior authorization was obtained
				remain subject to utilization review at any point in the payment
				process.
B. Eligibility
				determination: Prior authorization of services does not guarantee that
				individuals are eligible for HCA/ MAD programs. Providers must verify that
				individuals are eligible for HCA/MAD programs at the time services are
				furnished and determine if HCA/MAD program recipients have other health
				insurance.
C. Reconsideration:
				Providers who disagree with prior authorization request denials or other review
				decisions can request a rereview and a reconsideration. See Section MAD-953,
Reconsideration Of Utilization Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.20 - RESERVE BED DAYS

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid pays to hold or reserve a bed for a resident of an
				  ICF-MR for the following reasons:
1)
				to allow the resident to make home and community visits, e.g., vacations;
2) to adjust to a new living
				environment; or
3) for
				hospitalizations.
A. Coverage of reserve bed
				days: Without prior authorization, medicaid covers 65 reserve bed days per
				calendar year for every resident for family visits, vacations, home visits,
				hospitalizations and adjustment to a new living environment. Reserve bed days
				used under this section require documentation in the facility or the client
				records for all absences from the facility. If the absence from the facility is
				not documented in the facility or the client records, medicaid will recoup the
				reserve bed day payment. If the resident is away from the facility with
				facility staff supervision, the absence is not considered a reserve bed
				day.
B. Prior authorization: After
				the 65 days have been expended, medicaid covers, with prior authorization, an
				additional six reserve bed days per calendar year for discharge planning.
(1) A resident's discharge plan must clearly
				state the objectives, including how visits to alternative placements relate to
				discharge plan implementation.
(2)
				To obtain medicaid prior authorization, the facility must submit the following
				information in writing to MAD:
(a) the
				resident's name;
(b) social
				security number;
(c) requested
				approval dates;
(d) copy of the
				discharge plan;
(e) name and
				address of the individual who will care for the resident; and
(f) written physician order for trial
				placement.
(3)
				Documentation of the resident's absence from the facility for these six
				additional reserve bed days must be in the facility or the client records.
C. Documentation of
				reserve bed days: If residents leave the ICF-MR for any reason, documentation
				of the absence from the facility must be in the facility or client records.
				Hospitalizations must be documented in the client records at the
				ICF-MR.
D. Reimbursement and
				billing for reserve bed days: Reimbursement for reserve bed days to the ICF-MR
				is limited to the provider's level III rate. Billing for reserve bed days is
				based on the facility census, which runs from midnight to midnight. Medicaid
				pays for the admission day but does not pay for the discharge day. To receive
				payment for the additional six reserve bed days, which require prior
				authorization, the provider must attach a copy of the written notification of
				approval by MAD to the claim.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 2 - INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED › Section 8.313.2.21 - Reimbursement

Current through Register Vol. 35, No. 13, July 16, 2024
Intermediate care providers must submit claims for
				  reimbursement on the long term care turn around documents (TAD) or its
				  successor. See Section MAD-702,
Billing for Medicaid Services
.
				  Once enrolled, providers receive instructions on documentation, billing, and
				  claims processing.
A. MAD reimburses
				ICF-MR the lower of the following:
(1) the
				provider's billed charges; or
(2)
				the prospective rate as constrained by the ceilings established by MAD. See
				8.313.3 NMAC,
Cost Related Reimbursement of Intermediate Care
				Facilities for the Mentally Retarded
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
Health Care Authority, Medical Assistance
				  Division.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to the general public.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
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 Section 27-2-12 et. seq. NMSA
				  1978 (Repl. Pamp. 1991). 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.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.9 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico title XIX program makes reimbursement for
				  appropriately licensed and certified intermediate care facilities for the
				  mentally retarded as outlined in this material.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.10 - GENERAL REIMBURSEMENT POLICY

Current through Register Vol. 35, No. 13, July 16, 2024
The HCA will reimbursement ICF/ MR facilities the lower of
				  the following, effective September 1, 1990:
A. billed charges;
B. the prospective rate as constrained by the
				ceilings established by the HCA as described in this plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.11 - DETERMINATION OF ACTUAL, ALLOWABLE AND REASONABLE COSTS AND SETTING OF PROSPECTIVE RATES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Adequate cost data:
(1) Providers
				receiving payment on the basis of reimbursable cost must provide adequate cost
				data based on financial and statistical records which can be verified by
				qualified auditors. The cost data must be based on an approved method of cost
				finding and on the accrual basis of accounting. However, where governmental
				institutions operate on a cash basis of accounting, cost data on this basis
				will be acceptable, subject to appropriate treatment of capital
				expenditures.
(2) The cost finding
				method to be used by ICF-MR providers will be the step-down method. This method
				recognizes that services rendered by certain nonrevenue producing departments
				or centers are utilized by certain other non-revenue producing centers. All
				cost of non-revenue producing centers are allocated to all centers which they
				serve, regardless of whether or not these centers produce revenue. The cost of
				the non-revenue producing center serving the greatest number of other centers,
				while receiving benefits from the least number of centers, is apportioned
				first. Following the apportionment of the cost of the nonrevenue producing
				center, that center will be considered "closed" and no further costs will be
				apportioned to it. This applies even though it may have received some service
				from a center whose cost is apportioned later. Generally when two centers
				render services to an equal number, that center which has the greater amount of
				expense will be allocated first.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.12 - ESTABLISHMENT OF PROSPECTIVE PER DIEM RATES

Current through Register Vol. 35, No. 13, July 16, 2024
Prospective per diem rates will be established as follows and
				  will be the lower of the amount calculated using the following formulas, or any
				  applicable ceiling:
A. Base year:
(1) For implementation year one (effective
				September 1, 1990), the providers base year will be for cost reports filed for
				base year periods ending no later than June 30, 1990. Since these cost reports
				will not be audited at the time of implementation, an interim rate will be
				calculated and once the audited cost report is settled, a final prospective
				rate will be determined. Retrospective settlements of over or under payments
				resulting from the use of the interim rate will be made.
(2) Re-basing of the prospective per diem
				rate will take place every three years. Therefore, the operating years under
				this plan will be known as year one, year two, and year three. Since rebasing
				is done every three years, operating year four will again become year
				one.
(3) Costs incurred, reported,
				audited or desk reviewed for the provider's last fiscal year which falls in the
				calendar year prior to year one will be used to re-base the prospective per
				diem rate. Re-basing costs in excess of one hundred and ten percent of the
				previous year's reported cost per diem times the index (as described further on
				in these regulations) will not be recognized for calculation of the base year
				costs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.13 - ESTABLISHMENT OF CEILINGS

Current through Register Vol. 35, No. 13, July 16, 2024
Ceilings on the four major cost centers will be established
				  as follow:
A. Direct patient care: No
				ceiling will be imposed on this cost center.
B. A&G and R&B: The per diem costs
				for administration and general and for room and board will be grouped together
				for the establishment of a ceiling. This ceiling will be calculated at one
				hundred ten percent of the median of allowable costs for the base year, indexed
				to 12/31 of the base year. The ceiling will then be indexed to the mid-point of
				year one and set. For years two and three, the ceiling will not be
				recalculated, but rather will be indexed forward using the appropriate
				inflation factor described earlier in these regulations.
C. Facility cost:
(1) No ceiling will be imposed on this cost
				center, except in relation to leases.
(2) Effective for leases executed and binding
				on both parties on or after September 1, 1990, total allowable lease costs for
				the entire term of the lease for each facility will be limited to an amount
				determined by a discounted cash flow technique which will provide the lessor
				and annual rate of return on the fair market value of the facility equal to one
				times the average of the rates of interest on special issues of public debt
				obligations issued to the federal hospital insurance trust fund for the twelve
				months prior to the date the facility became a provider in the New Mexico
				medicaid program. The rates of interest for this fund are published in both the
				federal register and the commerce clearing house (CCH).
(3) The rate of return described above will
				be exclusive of any escalator clauses contained in the lease. The effect of
				escalator clauses will be considered at the time they become effective, and the
				reasonableness of such clauses will be determined by the inflation factor
				described in Subsection B of
				8.313.3.12 NMAC of these
				regulations.
(4) Any appraisal
				necessary to determine the fair market value of the facility will be the sole
				responsibility of the provider and is not an allowable cost for reimbursement
				under the program. The appraisals must be conducted by an appraiser certified
				by a nationally recognized entity, and such appraiser must be familiar with the
				health care industry, specifically long term care, and must be familiar with
				geographic area in which the facility is located. Prior to the appraisal taking
				place, the provider must submit to the HCA the name of the appraiser, a copy of
				their certification, and a brief description of the appraiser's relevant
				experience. The use of a particular appraiser is subject to the approval of the
				HCA.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.14 - ADJUSTMENTS TO BASE YEAR COSTS

Current through Register Vol. 35, No. 13, July 16, 2024
Since rebasing of the prospective per diem rate will take
				  place every three years, the HCA recognizes that certain circumstances may
				  warrant an adjustment to the base rate.
Therefore, the provider may request such an adjustment for
				  the following reasons:
A. Additional
				costs incurred to meet new requirements imposed by government regulatory
				agencies, taxation authorities, or applicable law (e.g. minimum staffing
				requirements, minimum wage change, property tax increases, etc.)
B. Additional costs incurred as a result of
				uninsurable losses from catastrophic occurrences.
C. Additional costs of approved expansion,
				remodeling or purchase of equipment.
D. Such additional costs must reach minimum
				of $5,000 for facilities with 16 or more beds and $1,000 for facilities with 15
				or less beds, of incurred cost per year for rebasing to be considered. The
				provider may request consideration of such rebasing no more than twice in its
				fiscal year. The provider is encouraged to submit such rebasing requests before
				the cost is actually incurred if possible. The HCA will approve or disapprove
				the rebasing request in a timely manner. If the rebasing is approved, the
				resulting increase in the prospective per diem rate will go into effect:
(1) beginning with the month the cost was
				actually incurred if prior approval was obtained, or
(2) no later than 30 days from the date of
				receipt of the request if retroactive approval was obtained. At no time will
				rebasing in excess of any applicable ceilings be allowed.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.15 - RESERVE BED DAYS

Current through Register Vol. 35, No. 13, July 16, 2024
Reserve bed days will be paid using the provider's level III
				  rate.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.16 - CAREGIVERS CRIMINAL HISTORY SCREENING

Current through Register Vol. 35, No. 13, July 16, 2024
The MAD will reimburse providers for the medicaid portion of
				  the billed amount that providers paid to the New Mexico department of health
				  (DOH). The following is the billing format.
A. Each ICF-MR will pay DOH by check
				according to DOH regulations.
B. A
				copy of the check(s) that the ICF-MR sent to DOH will be submitted to medicaid
				for payment on a quarterly basis on a medicaid reimbursement voucher (available
				at MAD or at MAD's designee).
C.
				Medicaid will only be responsible for the medicaid portion of the billed
				amount.
D. There will be a one-time
				charge to medicaid for fingerprinting equipment. Ongoing supplies, such as ink,
				rubber gloves, and other supplies, will be accounted for on the provider's cost
				report.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.17 - RECONSIDERATION PROCEDURES FOR BASE YEAR DETERMINATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A provider who is dissatisfied with the
				base year rate determination or the final settlement (in the case of a change
				of ownership) may request a reconsideration of the determination by addressing
				a request for reconsideration to: Director, Medical Assistance Division, P.O.
				Box 2348, Santa Fe, NM 87504
B. The
				filing of a request for reconsideration will not affect the imposition of the
				determination.
C. A request for
				reconsideration, to be timely, must be filed with or received by the medical
				assistance division no later than 30 days after the date of the determination
				notice to the provider.
D. The
				written request for reconsideration must identify each point on which it takes
				issue with the audit agent and must include all documentation, citation of HCA,
				and argument on which the request is based. Any point not raised in the
				original filed request may not be raised later.
E. The medical assistance division will
				submit copies of the request and supporting material to the audit agent. A copy
				of the transmittal letter to the audit agent will be sent to the provider. A
				written response from the audit agent must be filed with or received by the
				medical assistance division no later than 30 days after the date of the
				transmittal letter.
F. The medical
				assistance division will submit copies of the audit agent's response and
				supporting material to the provider. A copy of the transmittal letter to the
				provider will be sent to the audit agent. Both parties may then come up with
				additional submittals on the point(s) at issue. Such followup submittals must
				be filed with or received by the medical assistance division no later than 15
				days after the date of the transmittal letter to the provider.
G. The request for reconsideration and
				supporting materials, the response and supporting materials, and any additional
				submittal will be delivered by the medical assistance division director to the
				secretary, or their designee, within five days after the closing date for final
				submittals.
H. The secretary, or
				their designee, may secure all information and call on all expertise they
				believe necessary to decide the issues.
I. The secretary, or their designee, will
				make a determination on each point at issue, with written findings and will
				mail a copy of the determinations to each party within 30 days of the delivery
				of the material to him. The secretary's determinations on appeals will be made
				in accordance with the applicable provisions of the plan. The secretary's
				decision will be final and changes to the original determination will be
				implemented pursuant to that decision.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.18 - PUBLIC DISCLOSURE OF COST REPORTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Provider's cost reports submitted by
				participating providers as a basis for reimbursement as required by law are
				available to the public upon receipt of a written request to the medical
				assistance division. Information thus disclosed is limited to cost report
				documents required by social security administration regulations and, in the
				case of a settled cost report, the notice of program settlement.
B. The request must identify the provider and
				the specific report(s) requested.
C. The cost for copying will be charged to
				the requestor.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 313 - LONG TERM CARE SERVICES - INTERMEDIATE CARE FACILITIES › Part 3 - COST RELATED REIMBURSEMENT OF ICF-MR FACILITIES › Section 8.313.3.19 - SEVERABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If any provision of this regulation is held to be invalid,
				  the remainder of the regulations shall not be affected
				  thereby.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Health Care Authority.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
The rule applies to the general public.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
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 Section 27-2-12, NMSA 1978.
				  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.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
March 1, 2018 unless a later date is cited at the end of a
				  section.