reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Alternative benefits plan services with limitations (ABP):
The
				medical assistance division (MAD) category of eligibility "other adults" has an
				alternative benefit plan (ABP). The HSD contracted managed care organization
				(MCO) covers ABP specific services for an ABP member. 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 member has limitations on specific benefits; and
				does not have all MCO medicaid benefits available. All early and periodic
				screening, diagnosis and treatment (EPSDT) program services are available to an
				ABP member under 21 years. ABP services for an ABP member under the age of 21
				years are 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 MCO ABP contracted provider and an ABP member have rights and
				responsibilities as described in Title 8 Chapter 308 NMAC, Social
				Services.
B.
Alternative
				benefits plan general benefits for ABP exempt member (ABP exempt):
An
				ABP member who self-declares they have a qualifying condition is evaluated by
				the MCO's utilization management for determination if they meet the qualifying
				condition. An ABP exempt member utilizes their benefits described in 8.308.9
				NMAC and in 8.308.12 NMAC.
C.
Early childhood home visiting program:
A program that uses home
				visiting as a primary service delivery strategy and offers services on a
				voluntary basis to eligible pregnant individuals and their children from birth
				up to kindergarten entry, according to the program standard.
D.
Evidence-based, early childhood home
				visiting program:
A home visiting program that is recognized by the U.S.
				department of health & human services maternal, infant, and early childhood
				home visiting (MIECHV) project and:
(1) is
				grounded in relevant, empirically-based best practice and knowledge that:
(a) is linked to and measures the following
				outcomes:
(i) babies that are born
				healthy;
(ii) children that are
				nurtured by their parents and caregivers;
(iii) children that are physically and
				mentally healthy;
(iv) children
				that are ready for school;
(v)
				children and families that are safe; and
(vi) families that are connected to formal
				and informal supports in their communities;
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.8 - MISSION

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 9 - BENEFIT PACKAGE › Section 8.308.9.9 - BENEFIT PACKAGE

Current through Register Vol. 35, No. 13, July 16, 2024
This part defines the benefit package for which a MCO shall
				  be paid a fixed per-member-per-month capitated payment rate. The MCO shall
				  cover the services specified in 8.308.9 NMAC. The MCO shall not delete a
				  benefit from the MCO benefit package. A MCO is encouraged to offer value added
				  services that are not medicaid covered benefits or in lieu of services or
				  settings. The MCO may utilize providers licensed in accordance with state and
				  federal requirements to deliver services. The MCO shall provide and coordinate
				  comprehensive and integrated health care benefits to each member enrolled in
				  managed care and shall cover the physical health, behavioral health and
				  long-term care services per this section, its contract, and as directed by HSD.
				  If the MCO is unable to provide covered services to a particular member using
				  one of its contracted providers, the MCO shall adequately and timely cover
				  these services for that member using a non-contract provider for as long as the
				  member's MCO provider network is unable to provide the service. At such time
				  that the required services become available within the MCO's network and the
				  member can be safely transferred, the MCO may transfer the member to an
				  appropriate contract provider according to a transition of care plan developed
				  specifically for the member; see 8.308.11 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.10 - MEDICAL ASSISTANCE DIVISION PROGRAM RULES

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico administrative code (NMAC) rules and related
				  documents contain a detailed description of the services covered by MAD, the
				  limitations and exclusions to covered services, and non-covered services. The
				  NMAC rules are the official source of information on covered and non-covered
				  services. Unless otherwise directed, the MCO shall determine its own
				  utilization management (UM) protocols and shall comply with state and federal
				  requirements for UM including, but not limited to 42 CFR Part 456, which is
				  based on reasonable medical evidence. The MCO shall comply with the most
				  rigorous standards or applicable provisions of either NCQA, HSD regulation, the
				  Balanced Budget Act of 1997, or 42 CFR Part 438 related to timeliness of
				  decisions. The MCO shall ensure that medicaid covered benefits are furnished in
				  an amount, duration, and scope that is no less than the amount, duration, and
				  scope for the same services furnished to beneficiaries pursuant to
				  42 CFR
				  440.230. MAD may review and approve the MCO's
				  UM protocols. Unless otherwise directed by MAD, a HSD contracted MCO is not
				  required to follow MAD's reimbursement methodologies or MAD's fee schedules
				  unless otherwise required in a NMAC rule. The MCO shall comply with 42 CFR
				  Parts 438, 440, and 456.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.11 - GENERAL PROGRAM DESCRIPTION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				The MCO shall provide medically necessary services consistent with the
				following:
(1) a determination that a health
				care service is medically necessary does not mean that the health care service
				is a covered benefit; benefits are to be determined by HSD;
(2) in making the determination of medical
				necessity of a covered service the MCO shall do so by:
(a) evaluating the member's physical and
				behavioral health information provided by a qualified professional who has
				personally evaluated the member within their scope of practice; who has taken
				into consideration the member's clinical history, including the impact of
				previous treatment and service interventions and who has consulted with other
				qualified health care professionals with applicable specialty training, as
				appropriate;
(b) considering the
				views and choices of the member or their authorized representative regarding
				the proposed covered service as provided by the clinician or through
				independent verification of those views; and
(c) considering the services being provided
				concurrently by other service delivery systems;
(3) not denying physical, behavioral health
				and long-term care services solely because the member has a poor prognosis;
				medically necessary services may not be arbitrarily denied or reduced in
				amount, duration or scope to an otherwise eligible member solely because of his
				or her diagnosis, type of illness or condition;
(4) governing decisions regarding benefit
				coverage for a member under 21 years of age by the EPSDT program coverage rule
				to the extent they are applicable; and
(5) making services available 24 hours, seven
				days a week, when medically necessary and are a covered benefit.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.12 - GENERAL 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 member 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.
D.
Client transportation:
The
				benefit package covers expenses for transportation, meals, and lodging it
				determines are necessary to secure MAD covered medical or behavioral health
				examination and treatment for a MCO member in or out of his or her home
				community as detailed in 8.301.6, 8.324.7 and 8.310.2 NMAC.
E.
Community intervener:
The
				benefit package includes community intervener services. The community
				intervener works one-on-one with a deaf-blind member who is five-years of age
				or older to provide critical connections to other people and his or her
				environment. The community intervener opens channels of communication between
				the member and others, provides access to information, and facilitates the
				development and maintenance of self-directed independent living.
(1)Member eligibility: To be eligible for
				community intervener services, a member must be five-years of age or older and
				meet the clinical definition of deaf-blindness, defined as:
(a) the member has a central visual acuity of
				20/200 or less in the better eye with corrective lenses, or a field defect such
				that the peripheral diameter of visual field subtends an angular distance no
				greater than 20 degrees, or a progressive visual loss having a prognosis
				leading to one or both these conditions;
(b) the member has a chronic hearing
				impairment so severe that most speech cannot be understood with optimum
				amplification or the progressive hearing loss having a prognosis leading to
				this condition; and
(c) the member
				for whom the combination of impairments described above cause extreme
				difficulty in attaining independence in daily life activities, achieving
				psychosocial adjustment, or obtaining a vocation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.13 - SPECIFIC CASE MANAGEMENT PROGRAMS

Current through Register Vol. 35, No. 13, July 16, 2024
The benefit package includes case management services
				  necessary to meet an identified service need of a member. The following are
				  specific case management programs available when a member meets the
				  requirements of a specific service.
A.
Case management services for adults with developmental
				disabilities:
Case management services are provided to a member 21 years
				of age and older who is developmentally disabled as detailed in 8.326.2
				NMAC.
B.
Case management
				services for pregnant individuals and their infants:
Case management
				services are provided to a member who is pregnant up to 60 calendar days
				following the end of the month of the delivery as detailed in 8.326.3
				NMAC.
C.
Case management
				services for traumatically brain injured adults:
Case management
				services are provided to a member 21 years of age and older who is
				traumatically brain injured as detailed in 8.326.5 NMAC.
D.
Case management services for
				children up to the age of three:
Case management services for a member
				up to the age of three years who is medically at-risk due to family conditions
				and who does not have a developmental delay as detailed in 8.326.6
				NMAC.
E.
Case management
				services for the medically at risk (EPSDT):
Case management services for
				a member under 21 years of age who is medically at-risk for a physical or
				behavioral health condition as detailed in 8.320.2 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.16 - 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. The MCO shall implement written policies and
				  procedures approved by HSD which define how a member is educated about his or
				  her rights to family planning services, freedom of choice, to include access to
				  non-contract providers, and methods for accessing family planning
				  services.
A. The family planning
				policy shall ensure that a member of the appropriate age of both sexes who
				seeks family planning services shall be provided with counseling pertaining to
				the following:
(1) human immunodeficiency
				virus (HIV) and other sexually transmitted diseases and risk reduction
				practices; and
(2) birth control
				pills and devices including plan B and long acting reversible
				contraception.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.17 - PREVENTIVE PHYSICAL HEALTH SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall follow current national standards for
				  preventive health services, including behavioral health preventive services.
				  Standards are derived from several sources, including the U.S. preventive
				  services task force, the centers for disease control and prevention; and the
				  American college of obstetricians and gynecologists. Any preventive health
				  guidelines developed by the MCO under these standards shall be adopted and
				  reviewed at least every two years, updated when appropriate and disseminated to
				  its practitioners and members. Unless a member refuses and the refusal is
				  documented, the MCO shall provide the following preventive health services or
				  screens or document that the services (with the results) were provided by other
				  means. The MCO shall document medical reasons not to perform these services for
				  an individual member. Member refusal is defined to include refusal to consent
				  to and refusal to access care.
A.
Initial assessment:
The MCO shall conduct a health risk assessment
				(HRA), per HSD guidelines and processes, for the purpose of obtaining basic
				health and demographic information about the member, assisting the MCO in
				determining the need for a comprehensive needs assessment (CNA) for care
				coordination level assignment.
B.
Family planning:
The MCO must have a family planning policy. This
				policy must ensure that a member of the appropriate age of both sexes who seeks
				family planning services is provided with counseling and treatment, if
				indicated, as it relates to the following:
(1)
				methods of contraception; and
(2)
				HIV and other sexually transmitted diseases and risk reduction
				practices.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.18 - 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
.
A. The MCO must:
(1) promote and employ broad-based
				utilization of statewide access to Health Insurance Portability and
				Accountability Act (HIPAA)-compliant telemedicine service systems including,
				but not limited to, access to text telephones or teletype (TTYs) and 711
				telecommunication relay services;
(2) follow state guidelines for telemedicine
				equipment or connectivity;
(3)
				follow accepted HIPAA and 42 CFR part two regulations that affect telemedicine
				transmission, including but not limited to staff and contract provider
				training, room setup, security of transmission lines, etc; the MCO shall have
				and implement policies and procedures that follow all federal and state
				security and procedure guidelines;
(4) identify, develop, and implement training
				for accepted telemedicine practices;
(5) participate in the needs assessment of
				the organizational, developmental, and programmatic requirements of
				telemedicine programs;
(6) report
				to HSD on the telemedicine outcomes of telemedicine projects and submit the
				telemedicine report; and
(7) ensure
				that telemedicine services meet the following shared values, which are
				ensuring: competent care with regard to culture and language needs; work sites
				are distributed across the state, including native American sites for both
				clinical and educational purposes; and coordination of telemedicine and
				technical functions at either end of network connection.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.20 - COMMUNITY BENEFIT SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall cover community benefit services for a member
				  who meets the specific eligibility requirements for each MCO community benefit
				  service as detailed in 8.308.12 NMAC. When an additional community benefit
				  service is approved by MAD, the MCO shall cover that service as
				  well.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.21 - ALTERNATIVE BENEFITS PLAN (ABP) BENEFITS FOR ABP MCO MEMBERS

Current through Register Vol. 35, No. 13, July 16, 2024
The MAD category of eligibility "other adults" has an
				  alternative benefit plan (ABP). The MCO shall cover the ABP specific services
				  for an ABP member. Services are made available through a MCO under a benefit
				  plan similar to services provided by commercial insurance plans. ABP benefits
				  include preventive services and treatment services. An ABP member:
A. has limitations on specific
				benefits;
B. does not have all
				standard medicaid state plan benefits available; and
C. has some benefits, primarily preventive
				services that are available only to an ABP member. The ABP benefits and
				services are detailed in Sections 12 through 18 of 8.309.4 NMAC. All EPSDT
				services are available to an ABP member under 21 years. Services for an ABP
				member 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. The MCO shall comply with all HSD
				contractual provisions and with all NMAC rules that pertain to the MCO's
				responsibilities to its members as listed below:
(1) provider networks found in 8.308.2
				NMAC;
(2) managed care eligibility
				found in 8.308.6 NMAC;
(3)
				enrollment and disenrollment from managed care found in 8.308.7 NMAC;
(4) managed care member education - rights
				and responsibilities found in 8.308.8 NMAC;
(5) care coordination found in 8.308.10
				NMAC;
(6) transition of care found
				in 8.308.11 NMAC;
(7) managed care
				cost sharing found in 8.308.14 NMAC;
(8) managed care grievance and appeals found
				in 8.308.15 NMAC;
(9) managed care
				reimbursement found in 8.308.20 NMAC;
(10) quality management found in 8.308.21
				NMAC; and
(11) managed care fraud,
				waste and abuse found in 8.308.22 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.22 - MAD ALTERNATIVE BENEFITS PLAN GENERAL BENEFITS FOR ABP EXEMPT MEMBERS (ABP exempt)

Current through Register Vol. 35, No. 13, July 16, 2024
An ABP member who self-declares they have a qualifying
				  condition is evaluated by their MCO for determination if they meet an ABP
				  qualifying condition. An ABP exempt member may select to no longer utilize
				  their ABP benefits package. Instead, the ABP exempt member will utilize their
				  MCO's medicaid benefits package. See 8.308.9.11-20 NMAC for detailed
				  description of the MCO medicaid benefit services. All services, services
				  limitations and co-payments that apply to full benefit medicaid recipients
				  apply to APB-exempt recipients. An ABP-exempt recipient does not have access to
				  the benefits that 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 MCO shall comply
				  with all HSD contractual provisions and with all NMAC rules that pertain to the
				  MCO's responsibilities to its members as listed below:
A. provider networks found in 8.308.2
				NMAC;
B. managed care eligibility
				found in 8.308.6 NMAC;
C.
				enrollment and disenrollment from managed care found in 8.308.7 NMAC;
D. managed care member education - rights and
				responsibilities found in 8.308.8 NMAC;
E. care coordination found in 8.308.10
				NMAC;
F. transition of care found
				in 8.308.11 NMAC;
G. community
				benefits found in 8.308.12 NMAC;
H.
				managed care member rewards found in 8.308.13 NMAC
I. managed care cost sharing found in
				8.308.14 NMAC;
J. managed care
				grievance and appeals found in 8.308.15 NMAC;
K. managed care reimbursement found in
				8.308.20 NMAC;
L. quality
				management found in 8.308.21 NMAC; and
M. managed care fraud, waste and abuse found
				in 8.308.22 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.23 - CENTENNIAL HOME VISITING (CHV) PILOT PROGRAM SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Beginning January 1, 2019, the benefit is available to
				  approximately 300 eligible pregnant medicaid managed care enrolled members and
				  their children who reside in Bernalillo County (other HSD-designated counties
				  may be included at a later time and with a distinct enrollment limit) in
				  accordance with the program standard. The MCO shall contract with agencies
				  operating in the HSD-designated counties that provide services that are in
				  alignment with one of the two following evidence-based early childhood home
				  visiting delivery models:
A.
Nurse Family Partnership (NFP):
The services to be delivered under
				the NFP national program standards are for first-time parents only. In
				Bernalillo County, the program is anticipated to serve up to 132 families by
				the end of the first year of implementation using one NFP team and to
				approximately 240 eligible members (annual average at full implementation)
				thereafter using two NFP teams. The number of families served will be
				determined based on the number of active NFP teams in any program year. HSD may
				expand this program to other counties at HSD's discretion dependent upon
				provider capacity. The NFP services will be suspended once the child reaches
				two years of age.
B.
Parents
				as Teachers (PAT):
The PAT evidence-based program services will adhere
				to the national model and curriculum and serve approximately 60 families
				(annual average at full implementation) in Bernalillo County. Services will
				begin during pregnancy and may continue until the child reaches five years of
				age or kindergarten entry. HSD may expand this program to other counties at
				HSD's discretion dependent upon provider capacity. The number of families
				served in other counties will be determined based on the number of active PAT
				teams in the program year. The MCO may propose other evidence-based early
				childhood home visiting delivery models with similar services in lieu of the
				PAT model if available in the HSD-designated service areas.
C.
Description of Services:
The
				services available under the CHV pilot program are described below:
(1)
Prenatal home visits:
the
				benefit package includes the following services for eligible pregnant
				individuals during their pregnancy:
(a)
				monitoring for high blood pressure or other complications of pregnancy (only
				covered under the NFP model);
(b)
				diet and nutritional education;
(c)
				stress management;
(d) sexually
				transmitted disease (STD) prevention education;
(e) tobacco use screening and cessation
				education;
(f) alcohol and other
				substance misuse screening and counseling;
(g) depression screening; and
(h) domestic and intimate partner violence
				screening and education.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.24 - SERVICES EXCLUDED FROM THE MCO BENEFIT PACKAGE

Current through Register Vol. 35, No. 13, July 16, 2024
MAD does not cover some services. For the following services
				  that are covered in another MAP category of eligibility, reimbursement shall be
				  made by MAD or its contractor. However, the MCO is expected to coordinate these
				  services, when applicable, and ensure continuity of care by overseeing PCP
				  consultations, medical record updates and general coordination.
A.
Medicaid in the schools:
Services are covered under 8.320.6 NMAC. Reimbursement for services is made by
				MAD or its contractor.
B.
Special rehabilitation services-family infant toddler (FIT):
Early
				intervention services provided for a member birth to three years of age who has
				or is at risk for a developmental delay. Reimbursement for services is made by
				MAD or its contractor.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.25 - EMERGENCY AND POST STABILIZATION SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A. In this section, emergency medical
				condition means a medical condition manifesting itself by acute symptoms of
				sufficient severity (including severe pain) that a prudent layperson, who
				possesses an average knowledge of health and medicine, could reasonably expect
				the absence of immediate medical attention to result in the following:
(1) Placing the health of the individual (or,
				for a pregnant individual, the health of the individual or their unborn child)
				in serious jeopardy.
(2) Serious
				impairment to bodily functions.
(3)
				Serious dysfunction of any bodily organ or part.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.26 - ADDITIONAL COVERAGE REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The MCO may not arbitrarily deny or reduce
				the amount, duration, or scope of a required service solely because of
				diagnosis, type of illness, or condition of the member.
B. The services supporting members with
				ongoing or chronic conditions or who require long-term services and supports
				must be authorized in a manner that reflects the member's ongoing need for such
				services and supports.
C. Family
				planning services are provided in a manner that protects and enables the
				member's freedom to choose the method of family planning to be used consistent
				with 42 CFR 441.20, family planning services.
D. The MCO must specify what constitutes
				"medically necessary services" in a manner that:
(1) is no more restrictive than that used in
				the New Mexico administrative code (NMAC) MAD rules, including quantitative and
				non-quantitative treatment limits, as indicated in state statutes and rules.
				The state plan, and other state policy and procedures; and
(2) addresses the extent to which the MCO is
				responsible for covering services that address:
(a) the prevention, diagnosis, and treatment
				of a member's disease, condition, or disorder that results in health
				impairments or disability;
(b) the
				ability for a member to achieve age-appropriate growth and
				development;
(c) the ability for a
				member to attain, maintain, or regain functional capacity; and
(d) The opportunity for a member receiving
				long-term services and supports to have access to the benefits of community
				living, to achieve person-centered goals, and live and work in the setting of
				his or her choice.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 10 - CARE COORDINATION › Section 8.308.10.3 - 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 10 - CARE COORDINATION › Section 8.308.10.6 - 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 10 - CARE COORDINATION › Section 8.308.10.9 - CARE COORDINATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
General requirements:
(1) Care
				coordination services are provided and coordinated with the eligible recipient
				member and his or her family, as appropriate. Care coordination involves, but
				is not limited to, the following: planning treatment strategies; developing
				treatment and service plans; monitoring outcomes and resource use; coordinating
				visits with primary care and specialists providers; organizing care to avoid
				duplication of services; sharing information among medical and behavioral care
				professionals and the member's family; facilitating access to services; and
				actively managing transitions of care, including participation in hospital
				discharge planning. Managed care organizations (MCOs) may delegate care
				coordination functions through a full delegation model or a shared functions
				model, while retaining oversight of all care coordination activities.
(a) Full delegation model allows the MCO to
				delegate the full set of care coordination functions to a provider/health
				system (delegate) through a value-based purchasing (VBP) arrangement.
(b) Shared functions model allows the MCO to
				delegate some care coordination functions such as conducting health risk
				assessments, conducting comprehensive needs assessments, conducting periodic
				touch points, coordinating referrals to community services, and locating and
				engaging difficult to engage medicaid members.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 11 - TRANSITION OF CARE › Section 8.308.11.3 - 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 11 - TRANSITION OF CARE › Section 8.308.11.8 - MISSION

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 11 - TRANSITION OF CARE › Section 8.308.11.9 - TRANSITION OF CARE

Current through Register Vol. 35, No. 13, July 16, 2024
Transition of care refers to movement of an eligible
				  recipient or a manage care organization (MCO) member from one health care
				  practitioner or setting to another as their condition and health care needs
				  change. The MCO shall have the resources, the policies and the procedures in
				  place to actively assist the member with their transition of care.
A. Care coordination will be offered to
				members who are:
(1) transitioning from a
				nursing facility or out-of-home placement to the community;
(2) moving from a higher level of care to a
				lower level of care (LOC);
(3)
				turning 21 years of age;
(4)
				changing MCOs while hospitalized;
(5) changing MCOs during major organ and
				tissue transplantation services; and
(6) changing MCOs while receiving outpatient
				treatments for significant medical conditions. A member shall continue to
				receive medically necessary services in an uninterrupted manner during
				transitions of care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.3 - 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
., NMSA1978. 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 12 - COMMUNITY BENEFIT › Section 8.308.12.6 - 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 (MAD)
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.9 - MANAGED CARE COMMUNITY BENEFIT OPTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A MCO member, meeting a specific LOC, can select the approach
				  to receiving his or her community benefit services. The MCO offers two
				  approaches to the delivery of these services: agency based (ABCB) or
				  self-directed (SDCB). The MCO shall use the nursing facility (NF) LOC criteria
				  for determining medical eligibility for community benefits.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.10 - AGENCY BASED COMMUNITY BENEFIT (ABCB)

Current through Register Vol. 35, No. 13, July 16, 2024
The MCOs shall offer the ABCB approach to its members who
				  meets the NF LOC and are determined through a CNA or reassessment to need MCO
				  CB services. Although a member's assessment for the amount and types of
				  services may vary, ABCB services are not provided 24 hours per day. A member
				  has the option of choosing the ABCB or the SDCB approach. A member cannot
				  participate in both community benefit approaches concurrently.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.11 - ELIGIBLE ABCB PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
All ABCB agencies must apply and be approved to be a MAD
				  provider and must then contract with any or all approved MCOs. A complete
				  listing of all CB provider qualifications and responsibilities are detailed in
				  the MAD MCO policy manual. ABCB providers must meet all Federal requirements
				  for home and community based providers.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.12 - ELIGIBLE ABCB MEMBERS

Current through Register Vol. 35, No. 13, July 16, 2024
A member must meet NF LOC and be determined through a CNA or
				  reassessment to need MCO CB services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.13 - COVERED SERVICES IN AGENCY BASED COMMUNITY BENEFIT (ABCB)

Current through Register Vol. 35, No. 13, July 16, 2024
A. Adult day
				health: adult day health services provide structured therapeutic, social and
				rehabilitative services designed to meet the specific needs and interests of a
				member that are incorporated into the member's care plan.
(1) Adult day health services are provided by
				a licensed community-based adult day-care facility that offers health and
				social services to assist a member to achieve his or her optimal
				functioning.
(2) Private duty
				nursing services and skilled maintenance therapies (physical, occupational and
				speech) may be provided within the adult day health setting and in conjunction
				with adult day health services but are reimbursed separately from adult day
				health services.
(3) Adult day
				health settings must be integrated and support full access of individuals
				receiving medicaid home and community-based services (HCBS) to the greater
				community, engage in community life, control personal resources, and receive
				services in the community, to the same degree of access as individuals not
				receiving medicaid HCBS.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.14 - ABCB NON-COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD and the member's MCO do not cover certain procedures,
				  services, or miscellaneous items. See specific MAD NMAC rules, sections of this
				  rule, and the MAD MCO manual for additional information on benefit coverage and
				  limitations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.15 - SELF-DIRECTED COMMUNITY BENEFIT (SDCB)

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall offer the SDCB approach to a member who meets a
				  NF LOC and is determined through a CNA or reassessment to need CB services.
				  Self-direction affords a member the opportunity to have choice and control over
				  how his or her CB services are provided and who provides the services. Although
				  a member's assessment for the amount and types of services may vary, SDCB
				  services are not provided 24 hours per day. Services are reimbursed according
				  to the MAD fee schedule that has a range of allowable reimbursement rates to a
				  provider of a specific service. The member's MCO approves the final
				  reimbursement rate for each provider of a CB service. A member has the option
				  of choosing the ABCB or the SDCB approach. A member cannot participate in both
				  community benefit approaches concurrently.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.16 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				FMA, member or his or her EOR shall verify that a potential provider meets all
				applicable qualifications prior to rendering a service. If a provider or
				employee is unable to pass a nationwide criminal history screening pursuant to
				NMSA 1978, 29-12-2 et seq. or is listed in the abuse registry as defined in
				11-7a-1 et seq., NMSA 1978 he or she may not be employed to render any service
				to the member. Following formal approval from the MCO, LRIs may serve as a SDCB
				provider under extraordinary circumstances in order to assure the health and
				welfare of the member and to avoid his or her institutionalization. The MCO
				shall make decisions regarding LRIs serving as providers for members on a case
				by case basis. Following formal approval from the MCO, a spouse of a member may
				serve as a provider under extraordinary circumstances in order to assure the
				health and welfare of the member and to avoid institutionalization. The MCO
				shall provide such approval on a case by case basis. SDCB providers must meet
				all Federal and state requirements for home and community based
				providers.
B. An EOR shall have an
				employment agreement or vendor agreement with each of the member's providers.
				The employee or vendor agreement template shall be prescribed by MAD. Prior to
				a payment being made to a provider for SDCB services, the FMA shall ensure
				that: the provider meets all qualifications; and an employee agreement or
				vendor agreement is signed between the EOR and the provider. A member's
				employee agreement shall be updated anytime there is a change in any of the
				terms or conditions specified in the agreement. Employee agreements and vendor
				agreements shall be signed by the new EOR when there is a change in EORs. A
				copy of each employee agreement or vendor agreement shall be provided to the
				member and EOR. Refer to the MAD MCO policy manual for a complete listing of
				all SDCB provider qualifications and responsibilities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.17 - ELIGIBLE MEMBERS

Current through Register Vol. 35, No. 13, July 16, 2024
A member must meet NF LOC, be determined through a CNA or
				  reassessment to need MCO CB services, and be approved by the member's MCO for
				  the SDCB approach.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.21 - TERMINATION FROM ABCB PCS/CDIRECTED OR SDCB

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO may involuntarily terminate a member from the
				  PCS/CDirected or the SDCB approach under any of the following
				  circumstances.
A. The member, the
				member's authorized representative or his or her EOR refuses to follow NMAC
				rules, the MAD MCO policy manual, or his or her MCO policies after receiving
				focused technical assistance on multiple occasions and support from his or her
				care coordinator, PCS agency or FMA, which is supported by documentation of the
				efforts to assist the member. For purposes of this rule, focused technical
				assistance is defined as a minimum of three separate occasions where the
				member, authorized representative or his or her EOR have received training,
				education or technical assistance, or a combination of both, from the MCO, the
				FMA, the PCS agency or MAD.
B.
				There is an immediate risk to the member's health or safety by continued
				consumer direction or self-direction of services, i.e., the member is in
				imminent risk of death or serious bodily injury. Examples include but are not
				limited to the following:
(1) the member
				refuses to include and maintain services in his or her PCS/CDirected or SDCB
				care plan that would address health and safety issues identified in the
				member's CNA or challenges the assessment after repeated and focused technical
				assistance and support from program staff, the care coordinator, PCS agency or
				the FMA;
(2) the member is
				experiencing significant health or safety needs and, refuses to incorporate the
				care coordinator's recommendations into his or her IPoC or care plan, or
				exhibits behaviors that endanger him or her or others;
(3) the member misuses his or her SDCB budget
				following repeated and focused technical assistance and support from the care
				coordinator and the FMA, which is supported by documentation;
(4) the member expends his or her entire SDCB
				budget prior to the end of the care plan year; or
(5) the member or authorized representative
				intentionally misuses the member's PCS/CDirected or SDCB services or
				goods.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 12 - COMMUNITY BENEFIT › Section 8.308.12.22 - ELECTRONIC VISIT VERIFICATION (EVV) SYSTEM

Current through Register Vol. 35, No. 13, July 16, 2024
A. The MCO, together with the other MCOs,
				shall contract with a vendor to implement an EVV system in accordance with the
				federal Twenty First Century Cures Act.
B. The MCO shall maintain an EVV system
				capable of leveraging up-to-date technology as it emerges to improve
				functionality in all areas of the state, including rural
				areas.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 13 - MEMBER REWARDS › Section 8.308.13.3 - 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 13 - MEMBER REWARDS › Section 8.308.13.9 - ELIGIBLE MEMBERS

Current through Register Vol. 35, No. 13, July 16, 2024
A member of a HSD contracted managed care organization (MCO)
				  is eligible to participate in the managed care member rewards program.
A. For a native American member who elects to
				opt out of receiving medical assistance division (MAD) services through a HSD
				contracted MCO, and retains MAP category of eligibility, he or she no longer
				will earn reward credits as of the last day of enrollment in his or her
				MCO.
B. Upon losing eligibility for
				continued enrollment in a HSD contracted MCO, the individual no longer will
				earn member reward credits.