reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.14 - DETERMINATION OF ACTUAL, ALLOWABLE, AND REASONABLE COSTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Adequate cost data:
(1) All hospitals must provide adequate cost
				data based on financial and statistical records which can be verified by
				qualified auditors. The hospital will submit a cost report each year. 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
				hospitals will be the step-down method. This method recognizes that services
				rendered by certain non-revenue-producing departments or centers are utilized
				by certain other non-revenue-producing centers. All costs 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 non-revenue-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 greatest amount
				of expense will be allocated first.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.15 - PUBLIC DISCLOSURE OF COST REPORTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. As required by law, cost reports submitted
				by participating providers as a basis for reimbursement are available to the
				public upon receipt of a written request to the medical assistance program
				audit agent. Disclosure information 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 MAD audit agent that its cost report has been
				requested, by whom the request was made, and that the provider shall have 10
				calendar days in which to comment to the requestor before the cost report is
				released.
D. The cost for copying
				will be charged to the requestor.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.16 - 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 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.3 - 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 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.6 - 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 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.8 - 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 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.9 - SWING BED HOSPITAL SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program (medicaid) pays for medically
				  necessary health services furnished to eligible recipients. To help New Mexico
				  recipients receive necessary services, the New Mexico medical assistance
				  division (MAD) pays for services furnished in general hospital settings which
				  can also be used interchangeably as high or low nursing facility beds. This
				  part describes eligible providers, covered services, service limitations, and
				  general reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.10 - 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 MAD, small rural hospitals that meet the following requirements
				are eligible to be reimbursed for providing services as swing bed providers:
(1) hospital is licensed and certified by the
				licensing and certification bureau of the New Mexico department of health (DOH)
				to participate in the medicare and/or the medicaid programs and has received
				additional certification from the DOH to act as a swing bed provider;
(2) hospital must have fewer than 100
				inpatient hospital beds, counting all inpatient hospital beds maintained by the
				hospital, exclusive of beds for newborns and intensive care beds; and
(3) hospital must be located in a rural area;
				any geographic area not designated as "urban" in the most recent census is
				considered "rural" for the purpose of this regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.11 - CONDITIONS OF PARTICIPATION

Current through Register Vol. 35, No. 13, July 16, 2024
To participate as a swing bed hospital, the facility must
				  comply with the following conditions:
A. be licensed and certified as meeting all
				the requirements for participation as a hospital;
B. meet the requirements for hospital
				providers of long term care services. See 42 CFR 405.1041;
C. conform to MAD policy regarding
				recipient's personal funds; and
D.
				have an addendum to the medicaid provider agreement which conveys approval for
				swing bed participation; hospitals which have a waiver of the twenty-four (24)
				hour coverage requirement of Section 1861(e)(s) of the Social Security Act are
				not eligible to participate as swing bed hospitals.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.12 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all specified medicaid participation requirements. See 8.302.1
				  NMAC,
General Provider Policies
. Providers must verify that
				  individuals are eligible for medicaid at the time services are furnished and
				  determine if medicaid recipients have other health insurance. Providers must
				  maintain records which are sufficient to fully disclose the extent and nature
				  of the services furnished to recipients. See 8.302.1 NMAC
General
				  Provider Policies
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers hospital and nursing facility (low or high
				  level) services which are medically necessary for the diagnosis and/or
				  treatment of an illness or injury as indicated by the condition of the
				  recipient.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Swing bed services are subject to the limitations and
				  coverage restrictions which exist for other medicaid services. See 8.301.3
				  NMAC,
General Noncovered Services
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.15 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid 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 approval and claims
				  processing.
A.
Prior
				approval:
All utilization review activities, including level of care
				determinations and length of stay assignments for recipients at a nursing
				facility are carried out according to established MAD policy. All physical
				therapy, occupational therapy, and speech therapy furnished to inpatients in
				swing bed facilities at a high or low level require prior approval. Services
				for which prior approval was obtained remain subject to utilization review at
				any point in the payment process.
B.
Eligibility determination:
Prior approval of services does not guarantee that individuals are eligible for
				medicaid. 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.
Reconsideration:
Providers who disagree with prior approval
				request denials and other review decisions can request a re-review and a
				reconsideration. See Section MAD-953,
Reconsideration of Utilization
				Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.16 - RECIPIENT PERSONAL FUNDS ACCOUNTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. As a condition for participation in
				medicaid, each swing bed provider must establish and maintain an acceptable
				system of accounting for a resident's personal funds when a Title XIX
				(medicaid) recipient requests that his/her personal funds be cared for by the
				facility. See
				42 CFR
				483.10(c).
(1) Requests for swing bed providers to care
				or not care for a recipient's funds must be made in writing and secured by the
				request to handle recipient's fund form or a letter signed by the recipient or
				his/her representative. The form or letter is kept in the recipient's file at
				the facility.
(2) A recipient's
				personal fund consists of a monthly maintenance allowable, established by MAD.
				If the recipient receives any income in excess of this allowance, the excess is
				applied to the cost of the recipient's medical care at the facility. This
				excess is reported as a medical care credit to the swing bed provider by the
				local county income support division (ISD) office, when applicable.
(3) All swing bed facilities must have
				procedures for handling of medicaid recipients' funds. These procedures must
				not allow the facility to commingle medicaid recipients' funds with facility
				funds.
(4) Swing bed facilities
				should use medicaid guidelines to develop procedures for handling recipient
				funds.
(5) Recipients have the
				right to manage their financial affairs and no facility can require recipients
				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 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.17 - PATIENT SELF DETERMINATION ACT

Current through Register Vol. 35, No. 13, July 16, 2024
All adult recipients must be informed of their right to make
				  health decisions, including their right to accept or refuse medical treatment,
				  as specific in the Patient Self-Determination Act. See
				  8.302.1.18
				  NMAC,
General Provider Policies
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.18 - RESERVE BED DAYS

Current through Register Vol. 35, No. 13, July 16, 2024
To allow recipients to visit family or friends for short
				  periods of approved therapeutic leave or to allow trial placement to adjust to
				  a new environment as part of a discharge plan, MAD pays the routine rate to
				  hold or reserve the bed for the recipient's return.
A.
Coverage of reserve bed days:
Medicaid covers six (6) reserve bed days per calendar year for every swing bed
				recipient at a high or low nursing facility level without prior approval of the
				reserve days for any reason other than acute hospitalization, including home
				visits and acclimation to a new environment. Medicaid covers an additional six
				(6) days per calendar year with prior approval for visits which help the
				recipient adjust to a new environment, as part of a discharge plan.
(1) In these cases, the recipient's discharge
				plan must clearly state objectives including how the home visit or visit to
				alternative placement relates to discharge implementation.
(2) The prior approval request must include
				the recipient's name, medicaid number, requested approval dates, and a copy of
				the discharge plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 5 - SWING BED HOSPITAL SERVICES › Section 8.311.5.19 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Swing bed providers must submit claims for reimbursement on
				  the long term care turn around document (TAD) or its successor. See 8.302.2
				  NMAC,
Billing for Medicaid Services
. Once enrolled, providers
				  receive instructions on documentation, billing, and claims processing. Swing
				  bed hospitals are paid for high and low nursing facility routine services at
				  the statewide average rates paid under the state plan during the previous
				  calendar year to nursing facilities, as appropriate.
A. The following services or items are
				considered routine and are reimbursed as part of the routine rate:
(1) regular room;
(2) dietary and nursing services;
(3) medical and surgical supplies, including
				syringes, catheters, ileostomy, and colostomy supplies;
(4) use of equipment and
				facilities;
(5) general services,
				including administration of oxygen and related medications, hand feeding,
				incontinence care, tray service and enemas;
(6) standard items furnished routinely to all
				patients, such as patient gowns, water pitchers, basins and bed pans;
(7) items stocked at nursing stations in
				gross supply and distributed or used individually in small quantities such as
				cotton balls, band aids, laxatives, stool softeners, aspirin, antacids, OTC
				ointments and tongue depressors;
(8) reusable items expected to be available,
				such as ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction
				equipment, oxygen administration equipment and other durable medical
				equipment;
(9) laundry services,
				including basic personal laundry;
(10) special dietary supplements used for
				tube feeding or oral feeding even if prescribed by a physician; and
(11) oxygen.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
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.
				  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 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
August 1, 2014, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instructions for the
				  service portion of the New Mexico medical assistance
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				"
Authorized representative
" means the individual designated to
				represent and act on the claimant's behalf. The eligible recipient or managed
				care organization (MCO) member's authorized representative must provide formal
				documentation authorizing the named individual or individuals to access the
				indentified case information for a specified purpose and time frame. An
				authorized representative may be an attorney representing a person or
				household, a person acting under the authority of a valid power of attorney, a
				guardian ad litem, or any other individual or individuals designated in writing
				by the eligible recipient or MCO member.
B. "
Designee
" means a state
				agency or an institution MAD has designated to be responsible for:
(1) conducting a preadmission screening and
				annual resident review (PASRR) level 1 screening to identify if a medical
				assistance program (MAP) eligible recipient or a MCO member has a mental
				illness or an intellectual disability; or
(2) conducting a PASRR level 2
				evaluation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To reduce the impact of poverty on people living in New
				  Mexico by providing support services that help families break the cycle of
				  dependency on public assistance.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.9 - NURSING FACILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance division (MAD) pays for
				  medically necessary health services furnished to eligible recipients and
				  members. To help New Mexico eligible recipients and members receive necessary
				  services, MAD pays for services furnished in nursing
				  facilities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Health care to eligible recipients or members is furnished by
				  a variety of providers and provider groups. The reimbursement and billing for
				  these services is administered by MAD. Upon approval of a New Mexico MAD
				  provider participation agreement (PPA) by MAD or its designee, licensed
				  practitioners, facilities and other providers of services that meet applicable
				  requirements are eligible to be reimbursed for furnishing covered services to
				  eligible recipients. A provider must be enrolled before submitting a claim for
				  payment to the MAD claims processing contractors or the MCO. MAD makes
				  available on the HSD/MAD website, on other program-specific websites, or in
				  hard copy format, information necessary to participate in health care programs
				  administered by HSD or its authorized agents, including program rules, billing
				  instructions, utilization review (UR) instructions, and other pertinent
				  materials. When enrolled, a provider receives instruction on how to access
				  these documents. It is the provider's responsibility to access these
				  instructions, to understand the information provided and to comply with the
				  requirements. The provider must contact HSD or its authorized agents to obtain
				  answers to questions related to the material. To be eligible for reimbursement,
				  a provider must adhere to the provisions of the MAD PPA and all applicable
				  statutes, regulations, and executive orders. MAD, its selected claims
				  processing contractor or the MCO issues payments to a provider using electronic
				  funds transfer (EFT) only. Eligible providers include:
A. nursing facilities (NF) which:
(1) are currently licensed and certified by
				the department of health (DOH) to meet MAD nursing facility conditions of
				participation; see 42 CFR Part 483, as amended;
(2) comply with the eligible recipient or MCO
				member resident's personal funds rules;
(3) comply with MAD, its UR or the MCO UR
				processes and agree to operate in accordance with all MAD NMAC rules, including
				the performance of discharge planning;
(4) comply with the NMAC MAD rules for the
				pre-admission screening and resident review (PASRR) of mentally ill and
				intellectually disabled program;
(5) ensure the required nurse aide training
				is implemented; and
(6) ensure that
				facilities with 60 or more MAD beds certify a minimum of four distinct beds in
				the medicare program;
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. A
				provider who furnishes services to a medicaid or other health care program
				eligible recipient or member must comply with all federal and state laws,
				regulations, and executive orders relevant to the provision of services as
				specified in the MAD PPA. A provider also must conform to MAD program rules and
				instructions as specified in the MAD NMAC rule manual and its appendices, and
				program directions and billing instructions, as updated. A provider is also
				responsible for following coding manual guidelines and centers for medicare and
				medicaid services (CMS) national correct coding initiatives (NCCI), including
				not improperly unbundling or upcoding services.
B. A provider must verify that an individual
				is eligible for a specific health care program administered by HSD and its
				authorized agents, and must verify the recipient's enrollment status at the
				time services are furnished. A provider must determine if an eligible recipient
				or member has other health insurance. A provider must maintain records that are
				sufficient to fully disclose the extent and nature of the services provided to
				an eligible recipient or member.
C.
				When services are billed to and paid by a MAD fee-for-service coordinated
				services contractor authorized by HSD, under an administrative services
				contract, the provider must also enroll as a provider with the coordinated
				services contractor and follow that contractor's instructions for billing and
				for authorization of services; see 8.302.1 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.12 - REQUIRED NURSING FACILITY SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A NF is required to provide the following to a MAP eligible
				  recipient or member resident.
A. Room
				and board.
B. Professional nursing
				services 24 hours a day, seven days a week. Professional nursing services are
				those services which are performed directly by a RN or a licensed practical
				nurse (LPN), under the direction of a MAD enrolled, and, as appropriate, MCO
				contracted medical practitioner.
C.
				Services of a RN are on an eight hours a day, seven days a week basis, and at
				least the services of a LPN at all other times.
D. Personal assistance services on a 24 hours
				a day, seven days a week basis. Personal assistance services are those
				services, other than professional nursing services, that are provided to an
				eligible recipient who, because of age, infirmity, physical or behavioral
				health limitations, requires assistance to accomplish activities of daily
				living.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A. MAD
				covers NF services identified as allowable costs; see 8.312.3 NMAC.
B. MAD covers physical, occupational and
				speech therapy services furnished to an eligible recipient or member residing
				in a NF in the following manner:
(1) if the
				eligible recipient or member is also eligible for medicare and the NF does part
				B billing, the co-payment or deductible is processed by MAD or the MCO for
				services is paid by MAD or the MCO;
(2) if the eligible recipient or member
				receives high NF level services, services are included in the MAD facility
				rate; or
(3) if eligible, the
				recipient or member receives low NF level services, services are billed
				separately by participating therapy providers.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
NF services are subject to the limitations and coverage
				  restrictions which exist for other MAD services. See also 8.310.2, 8.310.3,
				  8.312.3, 8.324.4 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.15 - ELIGIBLE RECIPIENT AND MEMBER PERSONAL FUND ACCOUNTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. As a condition for MAD provider
				participation, each NF must establish and maintain an acceptable system of
				accounting for an eligible recipient or member resident's personal funds when
				an eligible recipient or member requests that his or her personal funds be
				cared for by the facility. See
				42 CFR Section
				483.10(c) and see 7.9.2.22
				NMAC.
(1) Requests for a NF to care or not
				care for an eligible recipient or member resident's funds must be made in
				writing and secured by a request to handle recipient or member funds form or
				letter signed by the eligible recipient or member or his or her authorized
				representative. The form or letter is kept in the eligible recipient or
				member's file at the facility.
(2)
				An eligible recipient or member's personal fund consists of a monthly
				maintenance allowable, established by MAD. If the eligible recipient or member
				resident receives any income in excess of this allowance, the excess is applied
				to the cost of the eligible recipient or member resident's medical care at the
				NF. This excess is reported as a medical care credit to the facility by the
				local county income support division (ISD) office, when applicable.
(3) A NF must have procedures on the handling
				of eligible recipient or member residents' funds. These procedures must not
				allow the facility to commingle eligible recipient or member residents' funds
				with facility funds.
(4) A NF
				should use these applicable federal statutes, regulations and state rules to
				develop procedures for handling eligible recipient or member resident's
				funds.
(5) An eligible recipient or
				member resident has the right to manage his or her financial affairs and no NF
				can require an eligible recipient or member resident to deposit his or her
				personal funds with the NF.
(6) A
				NF must purchase a surety bond or furnish self-insurance to ensure the security
				of all personal funds deposited with the NF.
(7) Failure of a NF to furnish an acceptable
				accounting system constitutes a deficiency that must be corrected by the
				provider and verified by DOH survey teams.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.16 - RESERVE BED DAYS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD pays to hold or reserve a bed for an eligible recipient
				  or member resident in a NF to allow for the eligible recipient or member
				  resident to make a brief home visit, for acclimation to a new environment, or
				  for hospitalization according to the limits and conditions outlined
				  below.
A.
Coverage of reserve
				bed days:
MAD covers six reserve bed days per calendar year for every
				long term care eligible recipient or member resident for hospitalization
				without prior approval. MAD covers three reserve bed days per calendar year for
				a brief home visit without prior approval. MAD covers an additional six reserve
				bed days per calendar year with prior approval to support an eligible recipient
				or member resident to adjust to a new environment as part of the discharge
				plan.
(1) An eligible recipient or member
				resident's discharge plan must clearly state the objectives, including how the
				home visits or visits to alternative placement relate to discharge
				implementation.
(2) The prior
				approval request must include the eligible recipient or member resident's name,
				MAP identification number, requested approval dates, copy of the discharge
				plan, name and address for individuals who will care for the eligible recipient
				or member resident during the visit or placement and a written medical order
				for trial placement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.17 - LEVEL OF CARE DETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
Medical necessity, LOC, and length of stay determinations are
				  carried out in accordance with MAD UR instructions or the MAD MCO policy
				  manual, as authorized under Title XIX of the Social Security Act; see 8.310.2
				  and 8.350.4 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.18 - PRE-ADMISSION SCREENING AND RESIDENT REVIEW (PASRR) OF MENTALLY ILL AND INTELLECTUALLY DISABLED INDIVIDUALS

Current through Register Vol. 35, No. 13, July 16, 2024
As part of the initial NF communication form for a new
				  admission or as part of a subsequent specified review as determined by PASRR,
				  or a significant change review as indicated by the minimum data set (MDS) for
				  an eligible recipient or member resident with identified mental illness or is
				  intellectually disabled, the NF must complete a level I PASRR screening. See
				  Omnibus Reconciliation Acts of 1987 and 1990 as codified at
				  42 CFR
				  Section 483.100 Subpart C. See also
				  P.L.
				  104-315 which amends title XIX of the Social
				  Security Act effective October 19, 1996. This requirement applies to all
				  applicants or residents, regardless of payment source.
A.
Pre-admission screens not
				required:
Pre-admission screens do not need to be performed on the
				following eligible recipient or member resident:
(1) when admitted from the hospital whose
				attending physicians certify before admission to the NF that the eligible
				recipient or member resident is likely to require NF care for less than 30 days
				(as determined by PASRR review of the his or her level I screen data which was
				done prior to NF admission);
(2)
				when readmitted to NFs from a hospital to which he or she was transferred for
				the purpose of receiving care; and
(3) when transferred from one NF to another
				without an intervening hospital stay.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.19 - MINIMUM DATA SET

Current through Register Vol. 35, No. 13, July 16, 2024
A. A long
				term care facility participating in the medicare and is an enrolled MAD
				provider is required to conduct a comprehensive, accurate, standardized,
				reproducible assessment of each eligible recipient or member resident's
				functional capacity. See Sections 4201 (a)(3) and 4211 (a)(3) of the Omnibus
				Reconciliation Act (OBRA) of 1987.
B. The capacity assessment describes the
				resident's ability to perform daily life functions and any significant
				impairment in functional capacity. The assessment is based on a uniform MDS of
				core elements and common definitions specified by the secretary of the federal
				health and human services department. A NF is required to use the most current
				iteration of the MDS. A section of the MDS requires a NF to identify eligible
				recipient or member residents who may be interested in transitioning back to
				his or her community.
(1) The resident
				assessment instrument (RAI) is specified by the state. State RAIs include at
				least the health care financing administration MDS, triggers, resident
				assessment protocols (RAPs) and utilization guidelines.
(2) On a date to be specified by the federal
				government, NFs will be required to encode the MDS in machine-readable form.
				After that date, all MDS reporting will be done electronically.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.20 - MEDICAL CARE CREDITS

Current through Register Vol. 35, No. 13, July 16, 2024
If an eligible recipient or member resident is required to
				  pay a medical care credit, MAD or the MCO reimburses the NF for the difference
				  between the NF's reimbursable rate and the medical care credit. The NF is
				  responsible for collecting the amount reported as the medical care credit.
				  These medical care credit requirements also apply to co-payments and
				  deductibles for medicare crossover payments.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.21 - NURSE AIDE TRAINING

Current through Register Vol. 35, No. 13, July 16, 2024
Pursuant to the public health emergency declared by the
				  governor of New Mexico in Executive Order 2020-004 on March 11, 2020, and any
				  renewal and subsequent Executive Order, and the department of health and human
				  services centers for medicaid and medicaid services COVID-19 Emergency
				  Declaration Waiver of Subsection D of 42 C.F.R. 483.35 ,with the exception of
				  Subparagraph (i) of Paragraph (1) of Subsection D of 42 C.F.R. 483.35, the New
				  Mexico human services department does hereby waive enforcement of Paragraphs
				  (1) and (2) of Subsection A of Section 8.321.2.21 NMSA 1978, along with
				  Subsection A of Section 8.321.2.21 NMSA 1978. The NF will not be approved as a
				  MAD or MCO provider if the NF has been out of compliance with federal
				  requirement within the previous two calendar years.
A. Requirements for nurse aide training:
(1) Waived.
(2) Waived.
(3) A NF must ensure that students in the
				NATCEP programs do not perform any services for which they have not been
				trained and found proficient by instructors. A NF must ensure that all students
				in NATCEP programs are under the general supervision of licensed or registered
				nurses when they perform services for eligible recipient or member
				residents.
(4) A NF must furnish
				regular performance reviews and in-service education to ensure that individuals
				who serve as nurse aides are competent to perform nurse aide services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.22 - PATIENT SELF DETERMINATION ACT

Current through Register Vol. 35, No. 13, July 16, 2024
All adult eligible recipient or member residents of nursing
				  facilities must be informed of their right to make their own health decisions,
				  including the right to accept or refuse medical treatment as specified in the
				  Patient Self-Determination Act; see 8.302.1 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.23 - RESIDENT RIGHTS TO REQUEST AN ADMINISTRATIVE HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
An eligible recipient or member resident who believes that
				  the NF has erroneously determined that he or she should be transferred or
				  discharged may request a HSD administrative hearing. A NF must provide an
				  eligible recipient or member resident notice of the proposed transfer or
				  discharge. The notice must inform the eligible recipient or member resident of
				  his or her right to request a hearing, the method by which a hearing can be
				  requested and his or her right to present evidence in person or through his or
				  her authorized representative; see 8.354.2 NMAC and the MAD MCO policy
				  manual.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.24 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services are subject to utilization review for
				  medical necessity, inspection of care, 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 8.310.2 NMAC. The
				  provider must contact HSD or its authorized agents to request UR instructions.
				  It is the provider's responsibility to access these instructions or ask for
				  paper copies to be provided, to understand the information provided, to comply
				  with the requirements, and to obtain answers to questions not covered by these
				  materials.
A.
Prior
				approval:
Certain procedures or services can require prior approval from
				MAD, the MCO or their designee. Services for which prior approval was obtained
				remain subject to UR at any point in the payment process.
B.
Eligibility determination:
Prior authorization of services does not guarantee that an individual is
				eligible for MAD services or other health care programs. A provider must verify
				that an individual is eligible for a specific program at the time services are
				furnished and must determine if the eligible recipient or member has other
				health insurance.
C.
Reconsideration:
A provider who disagrees with a prior approval
				request denial or other review decisions can request a reconsideration of
				utilization review; see 8.350.2 NMAC
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 2 - NURSING FACILITIES › Section 8.312.2.25 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A NF provider must submit claims for reimbursement on the
				  long term care turn around document (TAD) or its successor; see 8.302.2
				  NMAC
.
A. MAD
				reimburses a NF at the lesser of the following:
(1) the NF's billed charges;
(2) the prospective reimbursement rates
				constrained by the ceilings established by MAD; see 8.312.3 NMAC; and
(3) the NF's billed charge must be its usual
				and customary charge for services; "usual and customary charge" refers to the
				amount which the individual provider charges the general public in the majority
				of cases for a specific procedure or service.
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 8.312.3.3 - 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. 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 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
September 1, 2021, unless a later date is cited at the end of
				  a section.
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 8.312.3.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule 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 312 - LONG TERM CARE SERVICES - NURSING SERVICES › Part 3 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES › Section 8.312.3.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.312.3.9 - COST RELATED REIMBURSEMENT OF NURSING FACILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico Title XIX program makes reimbursement for
				  appropriately licensed and certified nursing facility (NF) services as outlined
				  in this material.
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 8.312.3.10 - GENERAL REIMBURSEMENT POLICY

Current through Register Vol. 35, No. 13, July 16, 2024
The human services department will reimburse nursing
				  facilities (effective October 1, 1990, the skilled nursing
				  facility/intermediate care facility SNF/ICF distinction is eliminated; see
				  8.312.3.16
				  NMAC) the lower of the following, effective July 1, 1984:
A. billed charges; and
B. the prospective rate as constrained by the
				ceilings (8.312.3.16
				NMAC) established by the department as described in this plan.
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 8.312.3.11 - 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)
Cost
				finding:
The cost finding method to be used by NF providers will be the
				step-down method. This method recognizes that services rendered by certain
				non-revenue-producing departments or centers are utilized by certain other
				non-revenue-producing centers. All costs 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 non-revenue-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.