reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 13 - MEMBER REWARDS › Section 8.308.13.10 - REWARD CREDITS

Current through Register Vol. 35, No. 13, July 16, 2024
A member may earn reward credits when engaging in healthy
				  behaviors included in the member rewards program. Reward credits are determined
				  for specific member healthy behaviors. Details on the requirements to earn a
				  healthy behavior reward credit are made available to a member on MAD's website
				  and provided in writing to a member through his or her MCO.
A.
Maximum amount of a member's reward
				credit balance:
A member must use credits earned during the calendar
				year by the end of the following calendar year. Any credits that are not used
				by the end of the following calendar year in which they are earned are
				lost.
B.
Portability of
				reward credits:
A member may carry his or her reward credits when
				transitioning from one HSD contracted MCO to another HSD contracted MCO. When a
				member earns reward credits for a specific healthy behavior, he or she may not
				earn reward credits for the same healthy behavior within the same calendar year
				with his or her new MCO.
C.
Retention of reward credits:
A member's reward credit balance will
				be accessible for the member's use up to 365 days after he or she loses MAP
				eligibility. For a native American who was a member of a HSD contracted MCO,
				and later opts in to fee-for-service (FFS) administration of benefits, the
				previously earned MCO reward credits are accessible up to 365 days after the
				close of his or her HSD contracted MCO membership.
D. Reward credit disputes: If a member
				believes there is a discrepancy in the way his or her HSD contracted MCO has
				determined a reward credit or balance, the member shall contact his or her MCO
				for resolution.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 14 - CO-PAYMENTS › Section 8.308.14.3 - 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 308 - MANAGED CARE PROGRAM › Part 14 - CO-PAYMENTS › Section 8.308.14.6 - 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 308 - MANAGED CARE PROGRAM › Part 14 - CO-PAYMENTS › Section 8.308.14.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Co-payment:
A co-payment is a fixed dollar
				  amount that a medicaid recipient must pay directly to a provider for a service,
				  visit or item. A co-payment is to be paid at the time of service or receipt of
				  the item.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 14 - CO-PAYMENTS › Section 8.308.14.10 - MEMBER RIGHTS AND RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. When a MAD benefit has a co-payment
				assigned for a MAP category of eligibility, the eligible recipient will at the
				time of service make payment or make arrangements with the provider for payment
				at a later date.
B. A member shares
				the responsibility to track his or her co-payments for each quarter. The member
				has the right to request from his or her MCO at any time an account of his or
				her household's co-payment total per quarter. If the member believes he or she
				has met the household's out-of-pocket (OOP) limit, he or she may request that
				the provider wait to charge future co-payments if the member has contacted his
				or her MCO to determine if the OOP limit has been met.
C. If a member had reached his or her
				household OOP limit but was not aware of it at the time the member paid a
				co-payment, the provider must refund the member the co-payment.
(1) The provider must refund the member
				within 10 working days after the member requests a reimbursement of the paid
				co-payment or the member's MCO notifies the provider that the member's OOP
				limit has been met.
(2) The member
				may notify verbally or in writing his or her MCO of the provider's failure to
				refund the co-payment within the required timeframe.
(3) Failure of the MCO to intervene to have
				its contracted provider refund the co-payment within 10 working days of the
				member notifying the MCO constitutes a MCO adverse action and the member may
				file a MCO appeal and if applicable, a HSD administrative hearing. See 8.308.15
				and 8.352.2 NMAC for detailed information.
(4) The member may also contact the HSD
				office of inspector general after he or she has complied with Paragraph (2) and
				(3) above to report the provider's refusal to refund the member's co-payment as
				such action may result in a credible allegation of fraud.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 14 - CO-PAYMENTS › Section 8.308.14.11 - CO-PAYMENT AMOUNTS IN MANAGED CARE PROGRAMS

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid co-payment amounts and the application of
				  co-payments are determined by MAD. See
				  42 CFR
				  447.56,
limitations on premiums and
				  cost sharing
, and 8.302.2 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.3 - 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 Sections 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 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.6 - 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 division
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
"Administrative law judge (ALJ)"
means the hearing officer
				appointed by the HSD fair hearings bureau (FHB) to oversee the claimant's
				administrative hearing process, to produce an evidentiary record and render a
				recommendation to the medical assistance division (MAD) director.
B.
"Adverse action against a
				member"
is when a HSD managed care organization (MCO) intends or has
				taken action against a member of his or her MCO as in one or more of the
				following situations.
(1) An adverse benefit
				determination is the denial, reduction, limited authorization, suspension, or
				termination of a newly requested benefit or benefit currently being provided to
				a member including determinations based on the type or level of service,
				medical necessity criteria or requirements, appropriateness of setting, or
				effectiveness of a service other than a value-added service. It includes the
				following:
(a) a change to a level of care
				(LOC) benefit currently being received through a MCO, including a reduction or
				other change in the member's LOC, and a transfer or discharge of a nursing
				facility (NF) resident;
(b) the
				retrospective denial, reduction, or limited authorization of a benefit rendered
				which was provided on a presumed emergency basis, whether in or out of network,
				or provided without having received any required authorization or LOC
				determination prior to the service being rendered, with the exception of a MCO
				value-added service;
(c) the denial
				in whole or in part of a member's provider claim by the MCO regardless of
				whether the member is being held responsible for payment;
(d) the failure of the MCO, or its designee:
(i) to make a benefit determination in a
				timely manner;
(ii) to provide a
				benefit in a timely matter;
(iii)
				to act within the timeframes regarding the MCO's established member appeal
				requirements;
(e) the
				belief of a member, his or her authorized representative or authorized provider
				that the MCO's admission determination, LOC determination, or preadmission
				screening and annual resident review (PASRR) requirements determination is not
				accurate or the belief that the frequency, intensity or duration of the benefit
				is insufficient to meet the medical needs of the member. When the issue stems
				from a PASRR determination, the member will request a HSD PASRR administrative
				hearing governed by 8.354.2 NMAC instead of a MCO member appeal or a HSD
				administrative hearing; and
(f) the
				denial of a request to dispute a financial liability, including co-payments,
				premiums or other member financial liabilities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.9 - MCO PROVIDER GRIEVANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon a
				provider contracting with the MCO, the MCO shall provide at no cost a written
				description of its provider grievance policies and procedures to the provider.
				The MCO will notify each of its providers in writing of any changes to these
				policies and procedures. The description shall include:
(1) information on how the provider can file
				a MCO provider grievance and the MCO's resolution process;
(2) time frames for each step of the
				grievance process through its final resolution; and
(3) a description of how the provider's
				grievance is resolved.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.10 - MCO PROVIDER APPEALS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon a
				provider contracting with the MCO, the MCO shall provide at no cost a written
				description of its provider appeal policies and procedures and instructions on
				how to act as a member's authorized provider to the provider. The MCO will
				update in writing each of its providers with any changes to these policies and
				procedures. The MCO will additionally provide to a non-contracted provider who
				is seeking to or has rendered services or items to the MCO's member, policies
				and procedures informing the provider of his or her rights and responsibilities
				to be designated by a member or the member's authorized representative to act
				as his or her authorized provider, and how to request a MCO expedited or
				standard member appeal as the authorized provider.
(1) The description shall include:
(a) information on how the provider can file
				a MCO provider appeal and the resolution process;
(b) time frames for each step of the MCO
				provider appeal process through its final resolution; and
(c) a description of how the provider's MCO
				appeal is resolved.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.11 - GENERAL INFORMATION ON MCO MEMBER GRIEVANCES AND APPEALS PROCESSES

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon a member's
				enrollment:
(1) the MCO shall provide to the
				member and his or her authorized representative at no cost a written
				description of its member grievance and member expedited and standard appeal
				system and member expedited appeal system procedures and processes;
(2) the MCO will promptly provide in writing
				to each member, his or her authorized representative any changes to these
				procedures and processes. The description shall include:
(a) information on how the member or his or
				her authorized representative or authorized provider can request a MCO
				expedited or standard appeal, or how the member or his or her authorized
				representative can file a MCO member grievance; and the resolution processes
				for each;
(b) time frames for each
				step of the MCO member grievance and the MCO expedited and standard member
				appeal processes through to their final resolution;
(c) a description of how a MCO member's
				grievance or MCO expedited or standard member appeal is resolved;
(d) information that the MCO may have only
				one level of appeal for the member;
(e) in the case of a MCO that fails to adhere
				to the time frames for each step of its procedures and process, the member or
				his or her authorized representative is deemed to have exhausted the MCO's
				expedited or standard member appeal process and the member or his authorized
				representative may request a HSD expedited or standard administrative
				hearing.
(f) The MCO shall
				designate a specific employee as its member grievance and appeal manager with
				the authority to:
(i) administer the policies
				and procedures for resolution of a MCO member grievance and a MCO expedited or
				standard member appeal;
(ii) review
				patterns and trends in MCO member grievances, and MCO expedited or standard
				member appeals; and
(iii) ensure
				that punitive or retaliatory action is not taken against any member or his or
				her authorized representative that files a MCO member grievance or any member,
				his or her authorized representative or the authorized provider who requests a
				MCO expedited or standard member appeal.
(g) Prior to the MCO taking an adverse
				action, in order to avoid incomplete information during the MCO expedited or
				standard member appeal process or the HSD expedited or standard administrative
				hearing process, the MCO must contact the requesting provider for more
				information or justification regarding the request if lack of information or
				justification is likely to lead to the adverse action.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.12 - MCO MEMBER GRIEVANCE PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				The MCO shall provide to its member or his or her authorized representative
				reasonable assistance in completing grievance forms and completing procedural
				steps, including but not limited to:
(1)
				providing interpreter services; and
(2) providing toll-free numbers that have
				adequate TTY/TTD and interpreter capability.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.15 - CONTINUATION OF A DISPUTED CURRENT BENEFIT DURING THE MCO EXPEDITED AND STANDARD MEMBER APPEAL PROCESSES

Current through Register Vol. 35, No. 13, July 16, 2024
A member or his or her authorized representative or
				  authorized provider requesting a MCO expedited or standard member appeal of an
				  adverse action may request that the disputed current benefit continue during
				  the MCO expedited or standard member appeal process. However, if the date of
				  the MCO expedited or standard member appeal final decision letter is prior to
				  the effective date of the notice of action's adverse action effective date, the
				  MCO must continue the disputed current benefit up to the notice of action's
				  adverse action effective date.
A. A
				request for a continuation of the disputed current benefit shall be accorded to
				any member who or through the member's authorized representative or authorized
				provider requests the continuation of the disputed current benefit who also
				requests a MCO expedited or standard member appeal within 10 calendar days of
				the mailing of the notice of action or prior to the date the notice of action
				states the benefit will be terminated. When the mailing date of the notice of
				action is disputed or there is a discrepancy between the mailing date and the
				postmarked date, the postmarked date will prevail.
B. The continuation of a disputed current
				benefit is only available to a member who is currently receiving the disputed
				benefit at the time of the MCO's notice of action.
(1) The continuation of the disputed current
				benefit is the same as the member's current benefit, which includes the
				member's current allocation, budget or LOC.
(2) The MCO must provide written information
				in its notice of action of the member's or his or her authorized
				representative's or authorized provider's rights and responsibilities to
				continue the disputed current benefit during the MCO expedited or standard
				member appeal process and of the possible responsibility of the member to repay
				the MCO for the disputed current benefit if the MCO expedited or standard
				member appeal final decision upholds the MCO's adverse action. If it was a
				MCO-initiated expedited member appeal, the MCO cannot recover the cost of the
				disputed current benefit if the MCO's adverse action is upheld.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 15 - GRIEVANCES AND APPEALS › Section 8.308.15.16 - MCO EXPEDITED MEMBER APPEAL AND MCO STANDARD MEMBER APPEAL FINAL DECISION AND IMPLEMENTATION

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				MCO shall provide the member or his or her authorized representative and the
				provider (regardless if the provider was not the one requesting the MCO member
				appeal) with its MCO expedited or standard member appeal final decision within
				the required time frames and provide supporting documentation substantiating
				the MCO's decision.
B. When the MCO
				expedited or standard member appeal final decision reverses the MCO's adverse
				action in total and the disputed benefit was not furnished during the member's
				expedited or standard member appeal process, the MCO shall authorize or provide
				the disputed benefit promptly and as expeditiously as the member's health
				condition requires.
C. When the MCO
				expedited or standard member appeal final decision reverses the MCO's adverse
				action in total and the member, his or her authorized representative or
				authorized provider had requested and the member had received a continuation of
				the disputed current benefit during the MCO expedited or standard member appeal
				process, the MCO may not recover from the member the cost of the continued
				disputed current benefit furnished during the MCO expedited or standard member
				appeal process.
D. When the MCO
				expedited or standard member appeal final decision upholds the MCO's adverse
				action and the member or his or her authorized representative or authorized
				provider had requested and the member had received a continuation of the
				disputed current benefit, the MCO may recover from the member the cost of the
				disputed current benefit furnished during the MCO expedited or standard member
				appeal process if:
(1) the member, his or her
				authorized representative or authorized provider was informed in writing by the
				MCO that the member could be responsible for the cost of the disputed current
				benefit if the MCO expedited or standard member appeal final decision upholds
				the MCO adverse action; and
(2) the
				member or his or her authorized representative elects not to request a HSD
				expedited or standard administrative hearing of the disputed current
				benefit.
(3) A MCO cannot recover
				the cost of the continued disputed benefit regardless if the final decision is
				upheld or reverses the MCO adverse action when the MCO initiated the MCO
				expedited member appeal process. See Subsection E of
				8.308.15.13
				NMAC for detailed description of a MCO-initiated expedited member appeal
				process.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 20 - REIMBURSEMENT › Section 8.308.20.3 - 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, Section 27-1-12 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 308 - MANAGED CARE PROGRAM › Part 20 - REIMBURSEMENT › Section 8.308.20.6 - 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 division
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 20 - REIMBURSEMENT › Section 8.308.20.8 - 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 308 - MANAGED CARE PROGRAM › Part 20 - REIMBURSEMENT › Section 8.308.20.9 - REIMBURSEMENT FOR MANAGED CARE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Payment for services:
HSD shall make actuarially sound payments,
				in accordance with
				42 C.F.R.
				438.6(c), for the provision
				of the managed care medicaid benefit package, under capitated risk contracts to
				the designated managed care organizations (MCOs)
.
Rates whether
				set by HSD or negotiated between HSD and the MCO are confidential.
(1) At the sole discretion of HSD, rates
				shall be appropriate for the medicaid populations to be covered and the
				services to be furnished under the contract. Rates may be adjusted based on
				factors, including but not limited to, changes in the scope of work; CMS
				requiring a modification of the 1115(a) waiver; new or amended federal or state
				statutes, regulations or rules; inflation; significant changes in the
				demographic characteristics of the member population; or the disproportionate
				enrollment selection of the MCO by members in certain rate cohorts.
(2) The MCO shall be responsible for the
				provision of services for members during the month of capitation. A medicaid
				eligible recipient shall not be liable for debts or costs incurred by an MCO
				under the MCO's managed care contract for providing health care to them. This
				includes but is not limited to:
(a) the MCO's
				debts in the event of its insolvency;
(b) services provided to the member that are
				not included in the medicaid benefit package and for which HSD does not pay the
				MCO, e.g., value added services;
(c) instances when the MCO does not pay the
				health care provider who furnishes the services under contractual, referral, or
				other arrangement;
(d) payments for
				covered services furnished under contract, referral, or other arrangement to
				the extent that those payments are in excess of the amount that the member
				would owe if the MCO provided the service directly; and
(e) if a MCO member loses eligibility for any
				reason and is reinstated as eligible by HSD before the end of the month, the
				MCO shall accept a retroactive capitation payment for that month of eligibility
				and assume financial responsibility for all medically-necessary covered benefit
				services supplied to the member.
(3) Retroactive capitation payments may not
				be issued for a member for the same coverage month in which fee-for-service
				claims have already been paid by HSD except in special situations determined by
				HSD.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.3 - 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 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.6 - 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 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.9 - QUALITY MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A HSD managed care organization (MCO) quality management
				  program includes a philosophy, a method of management, and a structured system
				  designed to improve the quality of services; includes both quality assurance
				  and quality improvement activities; and is incorporated into the health care
				  delivery and administrative systems.
A. Quality management (QM) program structure:
				The MCO shall have QM structure and processes as detailed in the medicaid
				managed care services agreement or the medical assistance division (MAD)
				managed care policy manual.
B. QM
				program description: The MCO shall develop a written QM and a quality
				improvement (QI) program description that includes the requirements described
				in the medicaid managed care services agreement or the managed care policy
				manual.
C. QM and QI program
				principles: The MCO QM and QI programs are based on principles of continuous
				quality improvement (CQI) and total quality management (TQM). Such an approach
				will:
(1) recognize clinical and non-clinical
				opportunities are unlimited;
(2) be
				data driven;
(3) use real-time
				input from members and MCO contracted providers to develop CQI activities;
				and
(4) require on-going
				measurement of effectiveness and improvement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.10 - DISEASE MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO will have a disease management program as described
				  in the medicaid managed care services agreement or the managed care policy
				  manual.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.11 - CLINICAL PRACTICE GUIDELINES

Current through Register Vol. 35, No. 13, July 16, 2024
As described in the medicaid managed care services agreement
				  or the managed care policy manual, the MCO will have a process to adopt,
				  review, update and disseminate evidence-based clinical practice guidelines,
				  practice parameters, consensus statements, and specific criteria for the
				  provision of acute and chronic physical and behavioral health care
				  services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.12 - PERFORMANCE IMPROVEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO will implement performance assessment and improvement
				  activities as described in the medicaid managed care services agreement or the
				  managed care policy manual.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.13 - INCIDENT MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Critical incident reporting and management is considered
				  part of ongoing quality management. Critical incident reporting and analysis of
				  critical incident data helps to identify causes of adverse events in critical
				  care and areas of focus for implementation of preventative strategies.
A. MCO incident management principles: The
				implementation of incident management practices and effective incident
				reporting processes as described in the medicaid managed care services
				agreement or the managed care policy manual are based on the following MAD MCO
				principles:
(1) a member is expected to
				receive home and community based services free of abuse, neglect, and
				exploitation;
(2) training
				addresses the response to and the report of to include the documentation of a
				critical incident;
(3) a member,
				his or her authorized representative will receive information on his or her MCO
				incident reporting process; and
(4)
				good faith incident reporting of or the allegation of abuse, neglect or
				exploitation is free from any form of retaliation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.14 - EXTERNAL QUALITY REVIEW ORGANIZATION (EQRO)

Current through Register Vol. 35, No. 13, July 16, 2024
An EQRO will conduct independent reviews of the MCO's
				  external quality review (EQR) activities as detailed in the medicaid managed
				  care services agreement or the managed care policy manual.
A. The MCO shall fully cooperate with the
				following mandatory EQRO activities, such as:
(1) the validation of required performance
				improvement projects (PIP) as detailed in the medicaid managed care services
				agreement or the managed care policy manual;
(2) the validation of plan performance
				measures reported by the MCO as defined in the medicaid managed care services
				agreement or the managed care policy manual;
(3) a review to determine the MCOs'
				compliance with state standards for access to care, structure and operations,
				and QM and QI requirements; and
(4)
				the validation of network adequacy.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.15 - QUALITY MANAGEMENT COMMITTEE

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO must have a planned, systematic and ongoing process
				  for monitoring, evaluating and improving the quality and appropriateness of
				  services provided to its members. A QM committee will provide oversight to
				  quality monitoring and improvement activities, including safety review and the
				  assignment of accountability.
A.
Quality review:
(1) The MCO shall
				establish a review committee to act as the leadership body for QI activities.
				The review committee acts to identify and facilitate the accomplishment of a
				planned, systematic, valid, and valuable QM plan for members and its
				providers.
(2) The review committee
				will monitor key services delivered to members and associated supportive
				processes to include:
(a) the utilization of
				services;
(b) its member
				satisfaction;
(c) its clinical
				services, including disease management; and
(d) its administrative services.
(3) The review committee is
				authorized to take action upon issues related to member care and make
				recommendations related to contracts, compensation, and provider
				participation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.16 - MEDICAL RECORDS

Current through Register Vol. 35, No. 13, July 16, 2024
The member's medical records, as described in the medicaid
				  managed care services agreement or the managed care policy manual, shall be
				  legible, timely, current, detailed and organized to permit effective and
				  confidential patient care and quality reviews. The MCO shall:
A. have medical record confidentiality
				policies and procedures and medical record documentation standards for its
				providers and subcontractors;
B.
				have a process to review medical records to ensure compliance with MCO policy,
				procedures and standards;
C.
				cooperate with the EQRO in its review of medical records to ensure compliance
				with its medical record policy and standards;
D. provide HSD or its designee access to a
				member's medical and behavioral health records;
E. include provisions in contracts with
				providers for MCO and HSD or its designee, access to member medical records for
				the purposes of compliance or quality review;
F. ensure that the assigned primary care
				provider (PCP), the patient centered medical home or the patient centered
				health home maintain a primary medical and as appropriate, behavioral health
				record for each member; this record must contain sufficient information from
				each provider involved in the member's care to ensure continuity of
				care;
G. ensure all providers
				involved in the member's care have access to the primary medical record;
				and
H. have policies and processes
				that ensure the confidential transfer of medical and behavioral health
				information between its providers, its agencies or other health
				plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.17 - UTILIZATION MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A utilization management (UM) program is an
				  organization-wide, interdisciplinary approach of evaluating the medical
				  necessity, appropriateness, and efficiency of health care services. The MCO
				  shall have an UM program as described in the medicaid managed care agreement
				  services or the managed care policy manual.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.18 - ADVISORY BOARDS

Current through Register Vol. 35, No. 13, July 16, 2024
Advisory boards are federally mandated bodies that provide
				  ongoing venues for discussions of policy, operations, service delivery and
				  administrative issues for its members. The MCO will convene and facilitate an
				  advisory board of its members and a native American advisory board in
				  accordance with the requirements described in the medicaid managed care
				  services agreement or the managed care policy manual.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 21 - QUALITY MANAGEMENT › Section 8.308.21.19 - SATISFACTION SURVEYS

Current through Register Vol. 35, No. 13, July 16, 2024
For the MCO to maintain a comprehensive system of health
				  care that supports quality, as well as cost-effectiveness depends largely on
				  the satisfaction and cooperation of its members and its providers. The MCO will
				  regularly survey these groups following the requirements described in the
				  medicaid managed care services agreement or the managed care policy
				  manual.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 22 - FRAUD, WASTE AND ABUSE › Section 8.308.22.3 - 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, Section 27-1-12 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 308 - MANAGED CARE PROGRAM › Part 22 - FRAUD, WASTE AND ABUSE › Section 8.308.22.5 - 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 308 - MANAGED CARE PROGRAM › Part 22 - FRAUD, WASTE AND ABUSE › Section 8.308.22.6 - 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 division
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 22 - FRAUD, WASTE AND ABUSE › Section 8.308.22.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. "Abuse" is
				provider practices that are inconsistent with sound fiscal, business, or
				clinical practices, and result in unnecessary costs to the medicaid program, or
				in reimbursement of services that fail to meet professionally recognized
				standards for health care.
B.
				"Credible allegation of fraud" means an allegation, which has been verified by
				the state, from any source, including but not limited to the following:
(1) fraud hotline complaint;
(2) claims data mining;
(3) patterns identified through provider
				audits;
(4) civil false claims
				cases; or
(5) law enforcement
				investigations; see
				42
				CFR 455.2.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 22 - FRAUD, WASTE AND ABUSE › Section 8.308.22.8 - 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 308 - MANAGED CARE PROGRAM › Part 22 - FRAUD, WASTE AND ABUSE › Section 8.308.22.9 - FRAUD, WASTE AND ABUSE

Current through Register Vol. 35, No. 13, July 16, 2024
HSD is committed to aggressive prevention, detection,
				  monitoring, and investigation to reduce provider or member fraud, waste and
				  abuse. This rule applies to all individuals and entities participating in or
				  contracting with HSD or a MCO for provision or receipt of medicaid services. If
				  fraud, waste or abuse is discovered, HSD shall seek all remedies available to
				  it under federal and state statutes, regulations, rules.
A. Program integrity requirements: the MCO
				shall have a comprehensive internal program integrity and overpayment
				prevention program to prevent, detect, preliminarily investigate and report
				potential and actual program violations including detecting potential
				overutilization of services, drugs, medical supply items and equipment. The MCO
				shall:
(1) be responsible for preventing and
				identifying overpayments or improper payments made to its providers;
(2) have specific internal controls for
				prevention, such as claim edits, prepayment and post-payment reviews, and
				provider profiling; and
(3) verify
				that services are actually provided utilizing "explanation of medicaid
				benefits" (EOB) notices and performing audits, reviews, and preliminary
				investigations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.3 - 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, Section 27-1-12 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 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.5 - 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 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.6 - 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 division
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.8 - 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 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.9 - ALTERNATIVE BENEFITS PLAN SERVICES WITH LIMITATIONS (ABP)

Current through Register Vol. 35, No. 13, July 16, 2024
The medical assistance division (MAD) category of eligibility
				  "other adults" has an alternative benefit plan (ABP). MAD covers ABP specific
				  services for an ABP eligible recipient. Services are made available through MAD
				  under a benefit plan similar to services provided by commercial insurance
				  plans. ABP benefits include preventive services and treatment services. An ABP
				  eligible recipient:
(1) has
				limitations on specific benefits;
(2) does not have all standard medicaid state
				plan benefits available; and
(3)
				has some benefits, primarily preventive services, that are available only to an
				ABP eligible recipient. All early and periodic screening, diagnosis and
				treatment (EPSDT) program services are available to an ABP eligible recipient
				under 21 years. ABP services for an ABP eligible recipient under the age of 21
				years not subject to the duration, frequency, and annual or lifetime benefit
				limitations that are applied to an ABP eligible recipient 21 years of age and
				older. A MAD ABP provider and ABP eligible recipient have rights and
				responsibilities as described in chapters 349 through 352 of Title 8 NMAC,
				Social Services. Long term care in a nursing facility (NF), mi via and
				community benefits are not available to an ABP eligible recipient.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.10 - ALTERNATIVE BENEFITS PLAN GENERAL BENEFITS FOR ABP-EXEMPT ELIGIBLE RECIPIENTS (ABP-EXEMPT)

Current through Register Vol. 35, No. 13, July 16, 2024
An ABP eligible recipient who self-declares he or she has a
				  qualifying condition is evaluated by the MAD utilization review (UR) contractor
				  for determination of whether he or she meets the qualifying condition. An
				  ABP-exempt eligible recipient may select to no longer utilize his or her ABP
				  benefits package. Instead, the ABP-exempt eligible recipient would then utilize
				  the standard medicaid state plan benefit package. See Section 19 of this rule
				  for detailed descriptions of the standard medicaid state plan benefits. Long
				  term care in a nursing facility (NF), mi via and community benefits are
				  available to an eligible ABP-exempt recipient when all conditions for accessing
				  those services are met.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 309 - ALTERNATIVE BENEFIT PROGRAM › Part 4 - MAD ADMINISTERED BENEFITS AND LIMITATION OF SERVICES › Section 8.309.4.11 - MAD ABP GENERAL PROGRAM DESCRIPTION

Current through Register Vol. 35, No. 13, July 16, 2024
The ABP benefits and services are detailed in Sections 12
				  through 17 of this rule. The ABP-exempt benefits and services are detailed in
				  Section 19 of this rule.