New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.12 - COVERED OUT-OF-STATE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers services and procedure furnished by a provider
				  located within 100 geographical miles of the New Mexico border, even though the
				  road miles may be greater than 100 miles, to the same extent and using the same
				  coverage rules as for an in-state provider. See
				  8.302.4.9 NMAC,
out of
				  state and border area providers
. When it is the general practice for
				  an eligible recipient in a New Mexico locality to access medical services in a
				  location more than 100 geographical miles from the New Mexico border, MAD will
				  treat that out-of-state location as a border area. MAD covers services and
				  procedures furnished by a provider more than 100 geographical miles from the
				  New Mexico border, excluding Mexico, to the extent and using the same coverage
				  rules as for in-state provider when one or more of the following conditions are
				  met.
A. An eligible recipient is
				out-of-state at the time the services are needed and the delivery of services
				is of an emergent or urgent nature or if the eligible recipient's health would
				be endangered by traveling back to New Mexico. Services must be medically
				necessary to stabilize the eligible recipient's health and prevent significant
				adverse health effects, including preventable hospitalization. Claims for such
				services are subject to pre-payment or post-payment reviews to assure the
				emergent or urgent need or medical necessity of the services.
B. On-going-services provided by a medical
				assistance program within the state continue to be necessary when the eligible
				recipient is visiting another state.
C. Care is medically necessary for an
				eligible recipient that is placed by the state of New Mexico in foster care in
				an out-of-home placement or in an institution. Care is medically necessary for
				an eligible recipient that was adopted from New Mexico and resides
				out-of-state. If the agreement with the other state requires that state's
				medicaid program pay for covered services, MAD will only consider payment when
				a service is not covered by the other state and the eligible recipient would be
				eligible for that service if living in New Mexico.
D. Durable medical equipment, medical
				supplies, prosthetics or orthotics are purchased from out-of-state
				vendors.
E. Clinical laboratory
				tests, radiological interpretations, professional consultations or other
				services are performed by out-of-state laboratories but do not require the
				eligible recipient to leave the state.
F. Medical services or procedures considered
				medically necessary are not available in the state of New Mexico. All services
				that are not available in New Mexico require prior authorization when provided
				by an out-of-state provider. An out-of-state service may be limited to the
				closest provider or an otherwise economically prudent choice of provider
				capable of rendering the service.
G. Services, such as personal assistance, are
				needed by an eligible recipient out-of-state if that recipient is eligible to
				receive services through a medicaid home and community-based services waiver
				program and is traveling to another state.