New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 14 - CO-PAYMENTS › Section 8.308.14.9 - CO-PAYMENTS IN THE MEDICAID MANAGED CARE PROGRAM

Current through Register Vol. 35, No. 13, July 16, 2024
The medical assistance division (MAD) imposes co-payment
				  provisions on certain members, certain categories of eligibility and on certain
				  services. The member's HSD contracted managed care organization (MCO) is
				  required to impose co-payments as directed by MAD at 8.302.2 NMAC and in
				  accordance with federal regulations.
General requirements regarding
				  co-payments:
A.  The MCO or its
				contracted providers may not deny services for a member's failure to pay the
				co-payment amounts.
B. The MCO must
				take measures to educate and train both its contracted providers and members on
				co-payment requirements.
C. The MCO
				shall not impose co-payment provisions on certain services that, in accordance
				with federal regulations, are always exempt from co-payment provisions. See
				42 CFR
				447.56,
limitations on premiums and
				cost sharing
and 8.302.2 NMAC.
D. The MCO shall not impose co-payment
				provisions on certain member categories of eligibility that, in accordance with
				federal and state regulations and rules, are exempt from cost-sharing
				provisions.
E. Payments to MCO
				contracted providers: In accordance with
				42 CFR
				447.56,
limitations on premiums and
				cost sharing
,the MCO must reduce the payment it makes to a contracted
				provider by the amount of the member's applicable co-payment obligation,
				regardless of whether the provider has collected the payment.
F. At the direction of MAD, the MCO must
				report all co-payment amounts collected.
G. The MCO may not impose more than one type
				of co-payment for any service, in accordance with
				42
				CFR 447.52.
H. The MCO must track, by month, all
				co-payments collected from each individual member in the household to ensure
				that the household does not exceed the aggregate limit (cap). The cap is five
				percent of countable household income for all individual members in a
				household, calculated as applicable for a quarter. The MCO must be able to
				provide each household member, at his or her request, with information
				regarding co-payments that have been applied to claims for the
				member.
I. The MCO must report to
				the provider when a co-payment has been applied to the provider's claim and
				when a co-payment was not applied to the provider's claim. The MCO shall be
				responsible for assuring the provider is aware that:
(1) the provider shall be responsible for
				refunding to the member any co-payments the provider collects after the member
				has reached the co-payment cap (five percent of the member's household income,
				calculated on a quarterly basis) which occurs because the MCO was not able to
				inform the provider of the exemption from co-payment due to the timing of
				claims processing;
(2) the provider
				shall be responsible for refunding to the member any co-payments the provider
				collects for which the MCO did not deduct the payment from the provider's
				payment whether the discrepancy occurs because of provider error or MCO error;
				and
(3) failure to refund a
				collected co-payment to a member and to accept full payment from the MCO may
				result in a credible allegation of fraud, see 8.351.2 NMAC.