New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 291 - MEDICAID ELIGIBILITY - AFFORDABLE CARE › Part 400 - ELIGIBILITY REQUIREMENTS › Section 8.291.400.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Action: an
				approval, termination, suspension, or reduction of medicaid eligibility or a
				reduction in the level of benefits and services, including a determination of
				income for the purposes of imposing any premiums, enrollment fees, or
				cost-sharing. It also means determinations made by skilled nursing facilities
				and nursing facilities to transfer or discharge residents and adverse
				determination made by a state with regard to the preadmission screening and
				resident review requirements.
B.
				Advance payments of the premium tax credit (APTC): payment of the tax credits
				specified in Section 36B of the Internal Revenue Code which are provided on an
				advance basis to an eligible individual enrolled in a qualified health plan
				through an exchange.
C. Affordable
				Care Act (ACA): the Patient Protection and Affordable Care Act of 2010 (Public
				Law 111-148), as amended by the Health Care and Education Reconciliation Act of
				2010 (Public Law 111-152) and the Three Percent Withholding Repeal and Job
				Creation Act (Public Law 112-56).
D. Affordable insurance exchanges
				(exchanges): a governmental agency or non-profit entity that meets the
				applicable requirements and makes qualified health plans available to qualified
				individuals and qualified employers. Unless otherwise identified, this term
				refers to state exchanges, regional exchanges, subsidiary exchanges, and a
				federally-facilitated exchange.
E.
				Agency: the single state agency designated or established by a state to
				administer or supervise the administration of the medicaid state plan. This
				designation includes a certification by the state attorney general, citing the
				legal authority for the single state agency to make rules and regulations that
				it follows in administering the plan or that are binding upon local agencies
				that administer the plan.
F. Appeal
				record: the appeal decision, all papers and requests filed in the proceeding,
				and if a hearing was held, the transcript or recording of hearing testimony or
				an official report containing the substance of what happened at the hearing,
				and any exhibits introduced at the hearing.
G. Appeal request: a clear expression, either
				verbally or in writing, by an applicant, enrollee, employer, or small business
				employer or employee to have any eligibility determination or redetermination
				contained in a notice issued reviewed by an appeals entity.
H. Appeals entity: a body designated to hear
				appeals of eligibility determinations or redeterminations contained in notices,
				or notices issued in accordance with future guidance on exemptions.
I. Appeals decision: a decision made by a
				hearing officer adjudicating a fair hearing, including by a hearing officer
				employed by an exchange appeals entity to which the agency has delegated
				authority to conduct such hearings.
J. Applicable modified adjusted gross income
				(MAGI) standard: the income standard for each category of ACA
				eligibility.
K. Application: the
				single streamlined application required by ACA and other medicaid applications
				used by the agency.
L. Authorized
				representative: the agency must permit applicants and beneficiaries to
				designate an individual or organization to act responsibly on their behalf in
				assisting with the individual's application and renewal of eligibility and
				other ongoing communications with the agency.
(1) Such a designation must be in writing
				including the applicant's signature, and must be permitted at the time of
				application and at other times. Legal documentation of authority to act on
				behalf of an applicant or beneficiary under state law, such as a court order
				establishing legal guardianship or a power of attorney, shall serve in the
				place of written authorization by the applicant or beneficiary.
(2) Representatives may be authorized to:
(a) sign an application on the applicant's
				behalf;
(b) complete and submit a
				renewal form;
(c) receive copies of
				the applicant or beneficiary's notices and other communications from the
				agency; and
(d) act on behalf of
				the applicant or beneficiary in all other matters with the agency.
(3) The power to act as an
				authorized representative is valid until the applicant or beneficiary modifies
				the authorization or notifies the agency that the representative is no longer
				authorized to act on their behalf, or the authorized representative informs the
				agency that they are no longer acting in such capacity, or there is a change in
				the legal authority upon which the individual's or organization's authority was
				based. Such notice must be in writing and should include the applicant or
				authorized representative's signature as appropriate.
(4) The authorized representative is
				responsible for fulfilling all responsibilities encompassed within the scope of
				the authorized representation to the same extent as the individual they
				represent, and must agree to maintain, or be legally bound to maintain, the
				confidentiality of any information regarding the applicant or beneficiary
				provided by the agency.
(5) As a
				condition of serving as an authorized representative, a provider, staff member
				or volunteer of an organization must sign an agreement that they will adhere to
				the regulations relating to confidentiality (relating to the prohibition
				against reassignment of provider claims as appropriate for a health facility or
				an organization acting on the facility's behalf), as well as other relevant
				state and federal laws concerning conflicts of interest and confidentiality of
				information.