reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.12 - GENERAL ABP COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Ambulatory surgical services:
The benefit package includes
				surgical services rendered in an ambulatory surgical center setting as detailed
				in 8.324.10 NMAC.
B.
Anesthesia services:
The benefit package includes anesthesia and
				monitoring services necessary for the performance of surgical or diagnostic
				procedures as detailed 8.310.2 NMAC.
C.
Audiology services:
The
				benefit package includes audiology services as detailed in 8.310.2 and 8.324.5
				NMAC with some limitations. For a ABP eligible recipient 21 years and older,
				audiology services are limited to hearing testing or screening when part of a
				routine health exam and are not covered as a separate service. Audiologist
				services, hearing aids and other aids are not covered for an ABP
				recipient.
D.
ABP eligible
				recipient transportation:
The benefit package covers expenses for
				transportation, meals, and lodging it determines are necessary to secure MAD
				covered medical or behavioral health services for an ABP eligible recipient in
				or out of his or her home community as detailed in 8.310.2 NMAC.
E.
Dental Services:
The benefit
				package includes dental services as detailed in 8.310.2 NMAC.
F.
Diagnostic imaging and therapeutic
				radiology services:
The benefit package includes medically necessary
				diagnostic imaging and radiology services as detailed in 8.310.2
				NMAC.
G.
Dialysis
				services:
The benefit package includes medically necessary dialysis
				services as detailed in 8.310.2 NMAC. A dialysis provider shall assist an ABP
				eligible recipient in applying for and pursuing final medicare eligibility
				determination.
H.
Durable
				medical equipment and medical supplies:
The benefit package includes:
(1) durable medical equipment as detailed in
				8.310.2 NMAC;
(2) covered
				prosthetic and orthotic services as detailed in 8.310.2 NMAC and 8.324.5 NMAC;
				and
(3) medical supplies as
				detailed in 8.310.2 NMAC with some limitations; for an ABP eligible recipient
				21 years of age and older the only medical supplies that are covered:
(a) diabetic supplies, such as reagents, test
				strips, needles, test tapes, and alcohol swabs; and
(b) medical supplies that are a necessary
				component of durable medical equipment, medical supplies applied as part of a
				treatment in a practitioner's office, outpatient hospital, residential
				facility, as a home health service and in other similar settings are covered as
				part of a service (office visit), which are not reimbursed separately;
				and
(c) family planning
				supplies.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.13 - PHARMACY SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The benefit package includes pharmacy and related services,
				  as detailed in 8.324.4 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.14 - REPRODUCTIVE HEALTH SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The benefit package includes reproductive health services as
				  detailed in 8.310.2 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.15 - PREVENTATIVE PHYSICAL HEALTH SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The benefit package includes the current national standards
				  for preventive health services including behavioral health preventive services.
				  Standards are derived from several sources, including the United States
				  preventive services task force, the centers for disease control and prevention;
				  and the American college of obstetricians and gynecologists. Unless an ABP
				  eligible recipient refuses and the refusal is documented, MAD shall make
				  available the preventive health services or screens or document that the
				  services (with the results) were provided by other means. The MAD provider
				  shall document medical reasons not to perform these services for an individual
				  ABP eligible recipient. ABP eligible recipient refusal is defined to include
				  refusal to consent to and refusal to access care.
A.
Initial assessment:
A MAD
				ABP provider may assist the ABP eligible recipient with inquires to the MAD UR
				contractor for a NF assessment.
B.
Prenatal care and screenings:
The benefit package includes
				prenatal care and related services, as detailed in 8.310.2 NMAC.
C.
Preventive medicine and
				supplements:
(1) An ABP eligible
				recipient can receive supplements detailed below as medically indicated:
(a) aspirin to prevent cardiovascular disease
				for a female between the ages of 45 to 79 years when the potential benefit of a
				reduction of ischemic strokes outweighs the potential harm of an increase in
				gastrointestinal hemorrhage;
(b)
				aspirin to prevent cardiovascular disease for a male between the ages of 45 to
				79 years when the potential benefit due to a reduction in myocardial
				infarctions outweighs the potential harm due to an increase in gastrointestinal
				hemorrhage;
(c) vitamin D
				supplementation to prevent falls in a community-dwelling for an ABP eligible
				recipient 65 years of age and older who is at increased risk for
				falls;
(d) folic acid
				supplementation for all female ABP eligible recipients who are planning or are
				capable of pregnancy to take a daily supplement containing 0.4 to 0.8 mg of
				folic acid;
(e) iron
				supplementation for all asymptomatic ABP eligible recipients between the ages
				of six to 12 months who are at increased risk for iron deficiency anemia;
				and
(f) breast cancer preventive
				medication, such as chemoprevention, is made available.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.16 - TELEMEDICINE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The benefit package includes telemedicine services as
				  detailed in 8.310.2 NMAC
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.17 - BEHAVIORAL HEALTH SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The benefit package includes the behavioral health services
				  as detailed in 8.321.2 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.18 - EARLY AND PERIODIC SCREENING DIAGNOSIS AND TREATMENT SERVICES (EPSDT)

Current through Register Vol. 35, No. 13, July 16, 2024
The benefit package includes the delivery of the federally
				  mandated EPSDT program services [
				  42 CFR Section
				  441.57 ] provided by a primary care provider
				  (PCP) as detailed in 8.320.2 NMAC. These include the ABP benefit services found
				  in Sections 12 through 17 of this rule.
A.
General physical health EPSDT
				services:
MAD makes available access to early intervention programs and
				services for an ABP eligible recipient identified in an EPSDT screen as being
				at-risk for developing or having a severe emotional, behavioral or
				neurobiological disorder. Unless otherwise specified in a service rule, ESPDT
				services are for an ABP eligible recipient under 21 years of age. For detailed
				description of each service, see 8.320.2 and for school based health services,
				see 8.320.6 NMAC. Additional NMAC citations may be included as
				reference.
B.
Behavioral
				health EPSDT services:
The benefit package includes services provided by
				a behavioral health practitioner for an ABP eligible recipient. See 8.321.2
				NMAC for a detailed description of each service. MAD makes available access to
				early intervention programs and services for an ABP eligible recipient
				identified in his or her EPSDT screen as being at-risk for developing or having
				a severe emotional, behavioral or neurobiological disorder.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.19 - ABP-EXEMPT ELIGIBLE RECIPIENT GENERAL BENEFIT DESCRIPTION

Current through Register Vol. 35, No. 13, July 16, 2024
An ABP eligible recipient with a qualifying condition may
				  select ABP-exempt utilizing the standard medicaid state plan benefits. All
				  services, services limitations and co-payments that apply to full benefit
				  medicaid recipients are available to APB-exempt recipients. An ABP-exempt
				  recipient does not have access to the benefits that are only apply to ABP
				  recipients. The ABP co-payments do not apply to an ABP-exempt recipient. The
				  limitations on services that apply only to ABP-recipients do not apply to
				  ABP-exempt recipients. The following chapters of Title 8 Social Services NMAC
				  provide more detailed descriptions of services.
A. Chapter 301
medicaid
general benefit
				description
;
B. Chapter
				302
medicaid
general provider
				policies
;
C. Chapter 310
health care professional services
;
D. Chapter 311
hospital
				services
;
E. Chapter 312
long term care-nursing services
, with the exceptions detailed
				in Section 10 of this rule);
F.
				Chapter 313
long-term care facilities -intermediate care
				facilities
;
G. Chapter 314
long-term care services-waivers
;
H. Chapter 320
early and periodic
				screening, diagnosis and treatment (EPSDT)
;
I. Chapter 321
behavioral health
				services
;
J. Chapter 324
adjunct services
;
K. Chapter 325
specialty
				services
; and
L. Chapter
				326
case management services
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.20 - ABP AND ABP-EXEMPT ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Health care to an ABP eligible recipient is furnished by a
				  variety of providers and provider groups. Refer to the MAD NMAC specific
				  service rules for detailed description of unique provider requirements. For
				  general information, see 8.310.2 and 8.310.3 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.21 - ABP AND ABP-EXEMPT NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD does not cover certain procedures, services, or
				  miscellaneous items. Refer to the NMAC specific service rules for detailed
				  description of unique noncovered services. For general information, see 8.310.2
				  NMAC for physical health noncovered services, 8.320.2 NMAC for EPSDT noncovered
				  services, 8.320.6 for noncovered school-based health services, and 8.321.2 NMAC
				  for behavioral health noncovered services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.22 - ABP AND ABP-EXEMPT PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services are subject to UR for medical necessity and
				  program compliance. Refer to the NMAC specific service rule for detailed
				  description of the service's prior authorization and utilization review
				  requirements. For general information, see 8.310.2 and 8.310.3
				  NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.23 - ABP AND ABP-EXEMPT RECIPIENT RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Services provided may be subject to cost sharing
				  requirements. Please see 8.302.2 NMAC for more information on any required
				  recipient co-payments.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.3 - 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 NMSA 1978, Sections 27-2-12 et seq.
				  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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
January 1, 2014, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.6 - 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
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.8 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.9 - GENERAL PROGRAM DESCRIPTION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				The New Mexico medical assistance division (MAD) pays for medically necessary
				health care services furnished by a MAD enrolled medical provider. See
				42 CFR
				440.210; Section
				27-2-16
				NMSA 1978 (Repl. Pamp. 1991).
B.
				MAD pays for medically necessary behavioral health professional services
				including assessments, evaluations, and therapy required by the condition of
				the medical assistance program (MAP) eligible recipient. See
				42
				CFR Sections 440.40,
				440.60(a)
				and 441.571.
C. MAD covers services
				which are medically necessary for the diagnosis or treatment of illnesses,
				injuries or conditions of a MAP eligible recipient, as determined by MAD or its
				designee. All services must be furnished within the limits of the MAD New
				Mexico administrative code (NMAC) rules policies and instructions within the
				scope of practice defined by the provider's licensing board, scope of practice
				act, or regulatory authority. Any claim submitted for reimbursement is subject
				to review by MAD or its designee to verify the medical necessity of the
				service. All claims are subject to pre-payment or post-payment review and
				recoupment.
D. HSD, through MAD, is
				responsible for the administration of the medicaid program and other health
				care programs. This joint federal and state program provides payment for
				medically necessary health services furnished to MAP eligible
				recipients.
E. A provider must be
				eligible for participation as a MAD approved provider at the time services are
				furnished. MAD does not cover services performed during a time period when the
				provider or facility did not meet required licensing or certification
				requirement.
F. If a MAP eligible
				recipient is enrolled with a MAD managed care organization (MCO), the provider
				must contact that member's MCO for specific reimbursement information. A MCO
				contracted with the state of New Mexico is not required to follow the MAD
				fee-for-service (FFS) fee schedules or reimbursement methodologies unless
				otherwise instructed by MAD. Reimbursement arrangements are determined
				contractually between the MCO and the provider.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.10 - RELATIONSHIP TO MEDICARE

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers medically necessary health services furnished to a
				  MAP eligible recipient who meets specific income, resource and eligibility
				  standards. Medicare is a federal program which offers health insurance coverage
				  to MAP eligible recipient 65 years of age and older, to those who have received
				  disability benefits for 24 consecutive months, to those who have end stage
				  renal disease, and to other MAP eligible recipients as specified by other
				  provisions of the Social Security Act.
A. New Mexico has entered into an agreement
				with the social security administration to pay a medicaid MAP eligible
				recipient's premium for medicare part B, and under some circumstances, medicare
				part A premiums.
B. After medicare
				has made payment for services, MAD pays for the medicare co-insurance,
				deductible and copayment amounts for a MAP eligible recipient subject to the
				following reimbursement limitations.
(1)
				Medicaid payment for the co-insurance, deductible, copayment or other patient
				responsibility is limited such that the payment from medicare, plus the amount
				allowed by MAD for the co-insurance, copayment and deductible, shall not exceed
				the MAD allowed amount for the service. When the medicare payment exceeds the
				amount that medicaid would have allowed for the service, no payment is made for
				the co-insurance, copayment, deductible or other patient responsibility. The
				claim is considered paid in full. The provider may not collect any remaining
				portion of the medicare co-insurance, copayment or deductible from the MAP
				eligible recipient or his or her authorized representative. For services for
				which medicare part B applies a 50 percent co-insurance rate, medicare
				co-insurance, copayment and deductible amounts are paid at an amount that
				allows the provider to receive more than MAD allowed amount, not to exceed a
				percentage determined by HSD.
(2)
				MAD will pay toward the medicare co-insurance and deductible to the extent that
				the amount paid by medicare and the allowed medicare co-insurance, deductible
				and copayment together do not exceed the MAD allowable amount. MAD will pay the
				full medicare co-insurance and deductible when MAD does not have a specific
				amount allowed for the service. When MAD does not use an equivalent payment
				methodology for a service, the full coinsurance, deductible and copayment
				amounts will be paid. This occurs when providers are paid at encounter rates,
				percent of billed charges followed by cost settlements, or when providers are
				entitled to a full reimbursement rate such as for federally qualified health
				centers and hospital outpatient prospective payment system
				reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.11 - SERVICE LIMITATIONS AND RESTRICTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers the following services with the frequency limits
				  indicated. For purpose of this rule, a provider is considered part of the same
				  provider group if he or she practices in the same office or clinic or has
				  direct access to the MAP eligible recipient's medical or behavioral health
				  records. Exceeding these limits requires prior authorization.
A.
Office visits in a practitioner's
				office:
Visits are limited to one-per-day from the same provider or
				provider group, unless the claim documents a change in the MAP eligible
				recipient's condition that could not have been anticipated at the first
				visit.
B.
Physical medicine
				modalities in a professional practitioner's office:
These modalities are
				limited to three-per-month. The limit is met when the same modality is
				performed three times during a calendar month, when three different modalities
				are performed during a month, or when three different modalities are performed
				during one visit.
C.
Physical
				medicine procedures and kinetic activities in a professional practitioner's
				office:
These services are limited to three-per-month from the same
				provider or provider group. The limit is met when the same procedure is
				performed three times during a calendar month, when three different procedures
				are performed during a month, or when three procedures are performed during one
				visit.
D.
Manipulation,
				osteo-manipulative therapy, or myofacial release in a professional
				practitioner's office:
These services are limited to three manipulations
				per calendar month, regardless of the area or areas manipulated. The limit is
				met when a manipulation of three different areas or of the same area at three
				different visits is performed during a month.
E.
Medically necessary services:
All services are limited to those that are medically necessary, including the
				length of time and the frequency of service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.14 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services are subject to UR 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. 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 hard 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. When services are billed to and paid by a coordinated
				  services contractor authorized by HSD, the provider must follow that
				  contractor's instructions for authorization of services.
A.
Prior authorization:
Procedures or services may require a prior authorization from MAD or its
				designee. Services for which a prior authorization was obtained remain subject
				to UR at any point in the payment process, including after payment has been
				made. It is the provider's responsibility to contact MAD or its designee and
				review documents and instructions available from MAD or its designee to
				determine when a prior authorization is necessary
.
(1) Dental services: MAD covers certain
				services, including some diagnostic, preventive, restorative, endodontic,
				periodontic, removable prosthodontics, maxillofacial prosthetic, oral surgery,
				and orthodontic services only when a prior authorization is received from MAD
				or its designee. MAD covers medically necessary orthodontic services to treat
				handicapping malocclusions for a MAP eligible recipient under 21 years of age
				by prior authorization.
(2)
				Transplantation services
:
A written prior authorization must be
				obtained for any transplant, with the exception of a cornea and a kidney. The
				prior authorization process must be started by the MAP eligible recipient's
				attending PCP contacting the MAD UR contractor. Services for which prior
				approval was obtained remain subject to UR at any point in the payment
				process.
(3) Pregnancy termination
				services: Services to terminate a pregnancy do not require a prior
				authorization from MAD or its designee.
(4) Eligibility determination: The prior
				authorization of a service does not guarantee that an individual is eligible
				for MAD 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 a MAP eligible recipient has other health
				insurance.
(5) Reconsideration: A
				provider who disagrees with a prior authorization -request denial or another
				review decision can request reconsideration; see 8.350.2
				NMAC
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 3 - PROFESSIONAL PROVIDERS, SERVICES AND REIMBURSEMENT › Section 8.310.3.3 - 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 27-2-12 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 3 - PROFESSIONAL PROVIDERS, SERVICES AND REIMBURSEMENT › Section 8.310.3.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
January 1, 2023, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 3 - PROFESSIONAL PROVIDERS, SERVICES AND REIMBURSEMENT › Section 8.310.3.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these rules is to provide instruction for
				  the service portion of the New Mexico medical assistance programs
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 3 - PROFESSIONAL PROVIDERS, SERVICES AND REIMBURSEMENT › Section 8.310.3.8 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 3 - PROFESSIONAL PROVIDERS, SERVICES AND REIMBURSEMENT › Section 8.310.3.10 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers services and procedures that are medically
				  necessary for the diagnosis and treatment of an illness or injury as indicated
				  by the MAP eligible recipient's condition. All services must be furnished
				  within the limits of NMAC rules and benefits and within the scope and practice
				  of the provider's professional standards.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 3 - PROFESSIONAL PROVIDERS, SERVICES AND REIMBURSEMENT › Section 8.310.3.11 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Providers must submit claims for reimbursement on the
				  CMS-1500, American dental association (ADA), or universal billing (UB) claim
				  form or their successor or their electronic equivalents, as appropriate to the
				  provider type and service.
A. A
				provider is responsible for following coding manual guidelines and CMS national
				correct coding initiatives, including not improperly unbundling or upcoding
				services, not reporting services together inappropriately, and not reporting an
				inappropriate number or quantity of the same service on a single day. Bilateral
				procedures and incidental procedure are also subject to special billing payment
				policies. The payment for some services includes payment for other services.
				For example, payment for a surgical procedure may include hospital visits and
				follow up care or supplies which are not paid separately.
B. General reimbursement:
(1) reimbursement to professional service
				providers is made at the lesser of the following:
(a) the provider's billed charge;
				or
(b) the MAD fee schedule for the
				specific service or procedure;
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.3 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.5 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.6 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.8 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.9 - FEDERALLY QUALIFIED HEALTH CENTER 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 clients. To help New Mexico
				  clients receive necessary services, the New Mexico medical assistance division
				  (MAD) pays for covered outpatient services provided at federally qualified
				  health centers (FQHC's). This part describes eligible providers, covered
				  services, service limitations, and general reimbursement methodology. MAD
				  intends to follow federal regulation applicable to medicare where and if there
				  are any omissions in these regulations with respect to covered
				  services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.10 - 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, the following entities are eligible to be reimbursed for
				furnishing medical services as FQHCs:
(1)
				entities which receive a grant under Sections 245b, 254c, and 256 of the Social
				Security Act;
(2) entities which
				receive funding from such a grant under a contract with the recipient of such a
				grant indicated above which meet the requirements to receive a grant under
				Sections 245b, 254c, and 256 of the Social Security Act;
(3) entities which the secretary of the
				federal department of health and human services determines meet the
				requirements for receiving such a grant or entities which qualify through
				waivers authorized by the secretary of the department of health and human
				services; and
(4) outpatient health
				programs or facilities operated by a tribe or tribal organization under the
				Indian Self-Determination Act or by an urban Indian organizations receiving
				funds under the Indian Health Care Improvement Act for the provision of primary
				health services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid clients 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 clients have other health insurance. Providers must
				  maintain records which are sufficient to fully disclose the extent and nature
				  of the services provided to clients. See 8.302.1 NMAC,
General Provider
				  Policies
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.12 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
All services provided by the FQHC must be furnished in
				  accordance with applicable federal, state, and local laws and regulations and
				  must be furnished within the limitations applicable to medicaid-covered
				  benefits. If not specified in this section, MAD adopts definitions of coverage
				  delineated in the FQHC sections of medicare statutes. "Other ambulatory
				  services" offered by the FQHC are subject to the same medicaid limitations,
				  utilization review requirements, and coverage restrictions that exist for other
				  providers rendering the delineated service.
A. Physician services:
(1) Physician services are professional
				services that are performed by a physician, including psychiatrists, employed
				by or under contract with the FQHC.
(2) Services and supplies incident to a
				physician's professional service are covered if the service or supply meets
				delineated requirements. Services and supplies include the professional
				component of radiology services, laboratory services performed by the FQHC and
				specimen collection for laboratory services furnished by an off-site
				laboratory. To meet the definition of "incident to" a professional service, the
				service and supplies must be:
(a) of a type
				commonly furnished in a physician's office; within the meaning of the Code of
				Federal Regulations (CFR) page 128 Section 405.2413 (a) (1) 10-01-98
				edition;
(b) of a type commonly
				rendered either without charge or included in the FQHC encounter
				rate;
(c) furnished as an
				incidental, although integral, part of a physician's professional
				service;
(d) furnished under
				direct, personal supervision of a physician; and
(e) in the case of a service, furnished by a
				member of the FQHC's health care staff who is an employee of the FQHC or under
				contract with the FQHC.
(3) Inpatient hospital visits are those
				services furnished to an individual as a "patient" of the FQHC. Therefore, FQHC
				services furnished off-site (including those furnished to a person who is an
				inpatient of a hospital or nursing facility) will be considered FQHC services
				only if the physician's agreement with the FQHC requires that they seek
				compensation from the FQHC. (Section 4704 c of OBRA '90, amended Section 1905
				1,2.) (HCFA Letter #91-18 dated March 1991.)
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.13 - 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 Approval and
				  Utilization Review
. Once enrolled, providers receive instruction and
				  documentation forms necessary for prior approval and claims processing.
A. Prior approval: Certain procedures and
				services can require prior approval from MAD or its designee. 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
				the individuals are eligible for medicaid. Providers must verify that
				individuals are eligible for medicaid at the time services are furnished and
				determine if medicaid clients have other health insurance.
C. Reconsideration: Providers who disagree
				with prior approval request denials or other review decisions can request a
				rereview and a reconsideration. See 8.350.2 NMAC,
Reconsideration of
				Utilization Review Decisions.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.14 - NON-COVERED SERVICES AND SERVICE LIMITATION

Current through Register Vol. 35, No. 13, July 16, 2024
FQHC services are covered when provided in outpatient
				  settings only, including a client's place of residence, which may be a skilled
				  nursing facility or a nursing facility or other institution used as a client's
				  home. FQHC services are not covered in a hospital as defined in section
				  1861(e)(1) of the Act.
A. Service
				limitations: An FQHC may be compensated for provision of other "ambulatory
				services" covered in the medicaid fee-for-service program (per the Balanced
				Budget Act of 1997). However, an FQHC must meet licensing and certification
				requirements for those services as specified in the applicable MAD policy
				manual section for the specific service.
B. Location of clinic:
(1) Permanent unit: Objects, equipment, and
				supplies necessary for the provision of services furnished directly by the FQHC
				must be housed in a permanent structure. Each unit must have individual FQHC
				certification.
(2) Mobile unit: The
				objects, equipment, and supplies necessary for the provision of services
				furnished by the FQHC must be housed in an FQHC mobile structure which has
				fixed, scheduled locations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 4 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 8.310.4.15 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
FQHCs must submit claims for reimbursement on the UB-92 claim
				  form or its successor. See 8.302.2 NMAC,
Billing for Medicaid
				  Services
. Once enrolled, providers receive instructions on
				  documentation, billing, and claims processing. Interim reimbursement for
				  services provided by an FQHC is made by MAD based on submitted claims.
A. Initial rates: The initial interim rate
				for new FQHC providers will be the interim rate set by medicare.
B. Cost settlement:
(1) FQHCs must submit cost reports on an
				annual basis to MAD or its designee within the time frames specified by
				medicare. FQHCs will not be granted an extension to the cost report filing time
				frames.
(2) A final cost settlement
				based on the audit data will be made in accordance with delineated medicaid
				requirements or applicable medicare cost reimbursement principles when medicaid
				requirements are not specified. Final cost settlements are based on the
				allowable cost as audited or desk reviewed costs by MAD or its designee.
				"Allowable costs" are costs incurred by an FQHC which are reasonable in amount,
				proper and necessary for the efficient delivery of services by the FQHC (MAD or
				its designee will follow the HCFA Pub. 15-1 in determining allowable costs).
				The supporting documentation for "allowable costs" must be available upon
				request from MAD or its designee.
(3) MAD or its designee may reopen cost
				reports per HCFA Pub. 15-1 Section 2931 through 2932.1. Providers will be
				notified on a case-by-case basis thirty (30) days prior to any reopening. MAD
				uses the productivity standards used in the medicare cost report. However, MAD
				does not use the costs limits imposed by medicare. If an FQHC disagrees with an
				audit settlement, the provider can request a reconsideration. See 8.350.4 NMAC,
Reconsideration of Audit Settlement.
(4) HCA or its designee will complete their
				initial review of cost settlement materials within 150 days of the receipt of
				all required information.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.3 - 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 Sections 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
January 1, 2014, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.6 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.8 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.9 - RURAL HEALTH CLINIC 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 rural New
				  Mexico recipients receive necessary services, the New Mexico medical assistance
				  division (MAD) pays for covered medicaid services provided in rural health
				  clinics [
				  42
				  CFR Section 440.20 ]. This part describes
				  eligible providers, covered services, service limitations, and general
				  reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.10 - 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, the following providers are eligible to be reimbursed for
				furnishing services as rural health clinics:
(1) clinics certified as non-hospital based
				rural health clinics by the health care financing administration (HCFA)
				following a survey and recommendation from the licensing and certification
				bureau of the New Mexico department of health (DOH); or
(2) clinics which are integral parts of
				institutional providers, such as hospitals, skilled nursing facilities or home
				health agencies, that have been certified as hospital-based rural health
				clinics by the licensing and certification bureau of the DOH.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.11 - 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 provided to recipients. See 8.302.1 NMAC,
General
				  Provider Policies
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.12 - COVERED SERVICES AND SERVICE LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
All services provided by the clinic must be furnished in
				  accordance with applicable federal, state, and local laws and regulations and
				  must be furnished within the limitations applicable to medicaid covered
				  benefits.
A. The following are covered
				services:
(1) medically necessary diagnostic
				and therapeutic services, supplies, and treatment of medical conditions,
				including medically necessary family planning services; see Section MAD-762,
Reproductive Health Services
;
(2) laboratory and diagnostic imaging
				services for diagnosis and treatment; and
(3) surgical procedures, emergency room
				physician services, and inpatient hospital visits furnished at a different
				facility when performed by a physician under contract to a rural health
				clinic.