reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.16 - CANCELLATION OF INSURANCE

Current through Register Vol. 35, No. 13, July 16, 2024
Providers must not advise or recommend that eligible
				  recipients cancel their health coverage. Failure to comply with this provision
				  is grounds for termination of the provider agreement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.17 - MAD RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. MAD
				has the following responsibilities in administering the TPL program:
(1) determining the legal liability of third
				parties, including health insurers, in paying for the medical services
				furnished to eligible recipients
				42 CFR
				433.138(a);
(2) pursuing claims and recovery against
				third parties when the amount of the third party payment that HSD can
				reasonably expect to recover exceeds the cost of the recovery; and
(3) pays to the extent that the medicaid
				allowed amount exceeds the TPL amount after the amount of third party liability
				is established not to exceed any patient responsibility determined by another
				payer.
(4) The child support
				enforcement division (CSED) provides information to MAD or its contractors on
				cases identified by CSED as having health insurance. Unless the custodial
				parent and child have satisfactory insurance, absent parents can be ordered by
				the court to provide coverage for the child. See
				45 CFR
				303.31(b)(1). MAD transmits
				information on absent parents who are not providing health coverage, as
				required by court order, or who have health insurance available through an
				employer but have not obtained it for their dependents to CSED.
(5) The New Mexico IV-D agency establishes
				paternity and obtains support orders for medical payments. MAD notifies this
				agency of lapses and changes of coverage information when it is identified by
				MAD. See
				45 CFR
				303.31(b)(8). This
				notification takes place when MAD learns that claims for a dependent child are
				rejected by the health insurance companies of the absent parent because his or
				her policy have been canceled, revised or no longer cover the child receiving
				IV-D services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.18 - INSURER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Individual, blanket, group accident or health policies or
				  certificates of insurance, including employee retirement income security Act
				  (ERISA) plans, delivered, issued or renewed in the state of New Mexico must not
				  contain exclusions or clauses which deny or limit insurance benefits to
				  eligible recipients because of their eligibility for medicaid benefits. See
				  Subsection D of Section 59-18-31 NMSA 1978 (Repl. Pamp. 1992).
A.
Direct payments to HSD:
All
				individual, blanket, or group accident or health policies or certificate of
				insurance, including ERISA plans, delivered, issued or renewed in the state of
				New Mexico must require insurers to reimburse HSD for benefits paid on behalf
				of eligible recipients in the following situations:
(1) HSD has paid or is paying
				benefits;
(2) HSD pays medicaid
				providers for the services in question; and
(3) insurers are notified that insured
				individuals receive medicaid benefits and that the benefits must be paid
				directly to HSD. HSD certifies to insurers at the time it files claims for
				reimbursement that these individuals are eligible for medicaid; and
(4) when the claim was paid by a MCO, payment
				may be made directly to the MCO. If the MCO fails to initiate recovery within
				12 months following the original payment date, the payment must be made to
				HSD.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.3 - 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 the Social Security Act as
				  amended, or by state statute. See Section 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 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instruction for the
				  service portion of the New Mexico medical assistance
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To reduce the impact of poverty on people living in New
				  Mexico and to assure low income and individuals with disabilities in New Mexico
				  equal participation in the life of their communities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.9 - OUT-OF STATE AND BORDER AREA PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Border area services are those that are rendered within 100
				  miles of the New Mexico state border (Mexico excluded). Out-of-state services
				  are those that are rendered in an area more than 100 miles from the New Mexico
				  border (Mexico excluded). To help New Mexico eligible recipients receive
				  medically necessary services, the medical assistance division (MAD) pays for
				  border area services to the same extent and subject to the same rules and
				  requirements that such services are covered when provided within the state. MAD
				  pays for out-of-state services as described under
				  8.302.4.12 NMAC,
covered
				  out-of-state services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Health care to eligible recipients is furnished by a variety
				  of providers and provider groups. The reimbursement and billing for these
				  services is administered by MAD. Upon approval of a New Mexico MAD provider
				  participation agreement by MAD or its designee, licensed practitioners,
				  facilities and other providers of services that meet applicable requirements
				  are eligible to be reimbursed for furnishing covered services to eligible
				  recipients. A provider must be enrolled before submitting a claim for payment
				  to the MAD claims processing contractors. MAD makes available on the HCA/MAD
				  website, on other program-specific websites, or in hard copy format,
				  information necessary to participate in health care programs administered by
				  HCA or its authorized agents, including program rules, billing instructions,
				  utilization review instructions, and other pertinent materials. When enrolled,
				  a provider receives instruction on how to access these documents. It is the
				  provider's responsibility to access these instructions, to understand the
				  information provided and to comply with the requirements. The provider must
				  contact HCA or its authorized agents to obtain answers to questions related to
				  the material or not covered by the material. To be eligible for reimbursement,
				  a provider must adhere to the provisions of the MAD provider participation
				  agreement and all applicable statutes, regulations, and executive orders. MAD
				  or its selected claims processing contractor issues payments to a provider
				  using electronic funds transfer (EFT) only. The providers listed in Subsections
				  A-C of 8.302.4.10 NMAC,
eligible
				  providers
, are eligible for a provider participation agreement, bill
				  and receive reimbursement for furnishing medical services:
A. Eligible providers include border area and
				out-of-state providers licensed by or certified by their respective states to
				practice medicine or osteopathy ; and other providers licensed or certified by
				their state to perform services equivalent to those covered by the medical
				assistance programs in New Mexico; practices or groups formed by these
				individuals may also receive reimbursement for services.
B. Eligible providers include border area
				providers within 100 miles of the New Mexico state border (Mexico excluded),
				subject to the rules governing the provision of services for an in-state
				provider.
C. Eligible providers
				include out-of-state providers more than 100 miles from the New Mexico state
				border (Mexico excluded), subject to the rules governing the provision of
				services for an in-state provider and any additional rules that may be
				specified for the specific services and providers within this manual.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. A
				provider who furnishes services to a medicaid or other health care program
				eligible recipient must comply with all federal and state laws, regulations and
				executive orders relevant to the provision of services as specified in the MAD
				provider participation agreement. A provider also must conform to MAD program
				rules and instructions as specified in the provider rules manual and its
				appendices, and program directions and billing instructions, as updated. A
				provider is also responsible for following coding manual guidelines and the
				centers for medicaid and medicare (CMS) correct coding initiatives, including
				not improperly unbundling or upcoding services. When services are billed to and
				paid by a coordinated services contractor authorized by HCA, the provider must
				follow that contractor's instructions for billing and for authorization of
				services.
B. A provider must verify
				that an individual is eligible for a specific health care program administered
				by the HCA and its authorized agents, and must verify the eligible recipient's
				enrollment status at the time services are furnished. A provider must determine
				if an eligible recipient has other health insurance. A provider must maintain
				records that are sufficient to fully disclose the extent and nature of the
				services provided to an eligible recipient.
C. When services are billed to and paid by a
				MAD fee-for-service coordinated services contractor authorized by HCA, under an
				administrative services contract, the provider must also enroll as a provider
				with the coordinated services contractor and follow that contractor's
				instructions for billing and for authorization of services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.13 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Services furnished by an out-of-state or border provider are
				  subject to the limitations and coverage restrictions which exist for other
				  services rendered in-state as stated in the relevant administrative, provider,
				  and other services sections of the MAD program policy manual. In addition, MAD
				  programs do not cover the following specific services when furnished by an
				  out-of-state or border provider:
A.
				services furnished outside the boundaries of the United States; and
B. services furnished in an out-of-state or
				border area nursing facility or intermediate care facility for the mentally
				retarded.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.14 - OUT-OF-STATE HOSPITAL SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
All out-of-state hospital, and other residential service
				  claims are subject to prepayment review or periodic re-authorization by MAD or
				  its designee for medical necessity and length of stay, in addition to requiring
				  authorization for the initial placement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.15 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services are subject to utilization review for
				  medical necessity and program compliance. Reviews can be performed before
				  services are furnished, after services are furnished, and before payment is
				  made, or after payment is made. See 8.302.5 NMAC,
Prior Authorization
				  and Utilization Review
. Once enrolled, a provider receives
				  instructions on how to access utilization review documents necessary for prior
				  approval and claims processing.
A.
				Prior authorization: Certain procedures or services can require prior approval
				from MAD or its designee. Services for which prior authorization was obtained
				remain subject to utilization review at any point in the payment process. A
				service provided through an out-of-state or border provider is subject to the
				same prior authorization and utilization review requirements, which exist for
				the service when not provided out-of-state.
B. Eligibility determination: Prior
				authorization of services does not guarantee an individual is eligible for
				medicaid and other health care programs. A provider must verify that an
				individual is eligible for a specific program at the time services are
				furnished and must determine if the eligible recipient has other health
				insurance.
C. Reconsideration: A
				provider who disagrees with prior authorization request denials and other
				review decisions can request a re-review and a re-consideration. See 8.350.2
				NMAC,
Reconsideration of Utilization Review Decisions.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.16 - OUT-OF-STATE BILLING OFFICES

Current through Register Vol. 35, No. 13, July 16, 2024
Services furnished within the state or border areas are
				  subject to the rules for instate providers even if the billing or
				  administrative office is outside the state.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 4 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.4.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Reimbursement to an out-of-state or border area provider is
				  made at the same rate as for an in-state provider except as otherwise stated in
				  the relevant specific providers and services sections of the MAD program rules
				  manual.
A. Unless payment for a
				service is made using a diagnosis related group or outpatient prospective
				payment system rate, reimbursement to a provider for covered services is made
				at the lesser of the following:
(1) the billed
				change which must be the provider's usual and customary charge for service;
				"usual and customary charge" refers to the amount which the individual provider
				charges the general public in the majority of cases for a specific procedure or
				service; or
(2) the MAD fee
				schedule for the specific service or procedure.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.3 - 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 2 - PROVIDER NETWORK › Section 8.308.2.10 - PRIMARY CARE PROVIDER (PCP)

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall ensure that each member is assigned a primary
				  care provider (PCP), except a member that is dually eligible for medicare and
				  medicaid (dual eligible). The PCP shall be a provider identified in Subsection
				  A below, participating in the MCO's network who will assume the responsibility
				  for supervising, coordinating, and providing primary health care to its member,
				  initiating referrals for specialist care, and maintaining the continuity of the
				  member's care. For a dual-eligible member, the MCO will be responsible for
				  coordinating the primary, acute, behavioral health and long-term care services
				  with the member's medicare PCP.
A.
				Types of PCPs: The MCO shall designate the following types of providers as a
				PCP as appropriate:
(1) medical doctors or
				doctors of osteopathic medicine with the following specialties: general
				practice, family practice, internal medicine, gerontology, gynecology and
				pediatrics;
(2) certified nurse
				practitioners, certified nurse midwives and physician assistants;
(3) specialists, on an individual basis, for
				members whose care is more appropriately managed by a specialist, such as
				members with infectious diseases, chronic illness, complex behavioral health
				conditions, or disabilities;
(4) a
				primary care team consisting of residents and a supervising faculty physician
				for contracts with teaching facilities or teams that include mid-level
				practitioners who, at the member's request, may serve as the point of first
				contact; in both instances the MCO shall organize its team to ensure continuity
				of care to the member and shall identify a "lead physician" within the team for
				each member; the "lead physician" shall be an attending physician; medical
				students, interns and residents may not serve as "lead physicians";
(5) federally qualified health centers
				(FQHC), rural health clinics (RHC), or Indian health service (IHS), tribal
				health providers, and urban Indian providers (I/T/U); or
(6) other providers that meet the
				credentialing requirements for PCPs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.13 - SPECIALTY PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall contract with a sufficient number of
				  specialists with the applicable range of expertise to ensure that the needs of
				  the members are met within the MCO's provider network. The MCO shall also have
				  a system to refer members to non-contracted providers if providers with the
				  necessary qualifications or certifications do not participate in the network.
				  Out-of-network providers must coordinate with the MCO with respect to payment.
				  The MCO must ensure that cost to its member is no greater than it would be if
				  the services were furnished within the network.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.14 - FAMILY PLANNING PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				The MCO shall give each adolescent and adult member the opportunity to use his
				or her own PCP or to use any family planning provider for family planning
				services without requiring a referral. Each female member shall also have the
				right to self-refer to a contracted women's health specialist for covered
				services necessary to provide women's routine and preventive health services.
				This right to self-refer is in addition to the member's designated source of
				primary care if that source is not a women's health specialist. Family planning
				providers, including those funded by Title X of the public health service,
				shall be reimbursed by the MCO for all covered family planning services,
				regardless of whether they are contracted providers of the member's MCO. Unless
				otherwise negotiated, the MCO shall reimburse providers of family planning
				services pursuant to the medicaid fee schedule.
B. Pursuant to state statute and rule, a
				non-contracted provider is responsible for keeping family planning information
				confidential in favor of the individual member even if the member is a minor.
				The MCO is not responsible for the confidentiality of medical records
				maintained by a non-contracted provider, but shall notify the non-contracted
				provider of the confidentiality provisions contained herein.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.15 - INDIAN HEALTH SERVICES, TRIBAL HEALTHCARE, AND URBAN INDIAN PROVIDERS (I/T/U)

Current through Register Vol. 35, No. 13, July 16, 2024
A. The MCO shall
				make best efforts to contract with I/T/Us in the state, including, but not
				limited to, contracting for such services as transportation, care coordination
				and case management. The MCO is encouraged to use the sample I/T/U addendum as
				described in
				42
				CFR 438.14 to develop an addendum specific to
				New Mexico that can be used to establish network provider agreements with
				I/T/Us as such agreements include the federal protections for I/T/Us.
B. The MCO shall allow native American
				members to seek care from any I/T/U whether or not the I/T/U is a contract
				provider and shall reimburse I/T/Us as specified in 8.308.20 NMAC. The MCO
				shall permit non-contracted I/T/Us to refer native American members to a
				contracted provider.
C. The MCO
				shall not prevent members from seeking care from I/T/Us or from contract
				providers due to their status as native Americans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.17 - PROVIDER TRANSITION

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall notify HSD within five calendar days of
				  unexpected changes to the composition of its provider network that would have
				  an effect on member access to services or on the MCOs ability to deliver
				  services included in the benefit package. Anticipated material changes in the
				  MCO provider network shall be reported in writing to HSD within 30 calendar
				  days prior to the change or as soon as the MCO becomes aware of the anticipated
				  change. For both expected and unexpected changes in the network, the MCO shall
				  be required to assess the significance of the change or closure to the network
				  and shall submit a notification narrative and specific transition plans, if
				  applicable, as detailed in the MCO policy manual.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.18 - DELEGATION

Current through Register Vol. 35, No. 13, July 16, 2024
Delegation is a process whereby a MCO gives another entity
				  the authority and responsibilities to perform certain functions on its behalf.
				  The MCO is fully accountable for all pre-delegation and delegation activities
				  and decisions made. The MCO shall document its oversight of the entity that
				  performs the delegated activity. The MCO may assign, transfer, or delegate to a
				  subcontractor key management functions with the explicit written approval of
				  HSD.
A. Each contract or written
				agreement between the MCO and delegated entity shall describe:
(1) the responsibilities of the MCO and the
				entity to which the activity is delegated;
(2) the delegated activities or
				obligations;
(3) the reporting
				responsibilities to include the frequency and method of reporting to the
				MCO;
(4) the process by which the
				MCO evaluates the delegated entity's performance;
(5) the remedies up to, and including,
				revocation of the delegation, available to the MCO if the delegated entity does
				not fulfill its obligations; and
(6) the requirements specified in
				42 CFR §
											438.214, if the delegated entity will be
				providing or securing covered services to members.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 6 - ELIGIBILITY › Section 8.308.6.3 - 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 6 - ELIGIBILITY › Section 8.308.6.8 - 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 6 - ELIGIBILITY › Section 8.308.6.9 - MANAGED CARE ELIGIBILITY

Current through Register Vol. 35, No. 13, July 16, 2024
A. General
				requirements: HSD determines eligibility for medicaid. An eligible recipient is
				required to participate in a HSD managed care program unless specifically
				excluded as listed below. Enrollment in a particular managed care organization
				(MCO) will be according to the eligible recipient's selection of a MCO at the
				time of application for eligibility, or during other permitted selection
				periods, or as assigned by HSD, if the eligible recipient makes no
				selection.
B. The following
				eligible recipients, as established by their eligibility category, are excluded
				from managed care enrollment:
(1) qualified
				medicare beneficiaries (QMB)-only recipients;
(2) specified low income medicare
				beneficiaries (SLIMB) only;
(3)
				qualified individuals;
(4)
				qualified disabled working individuals;
(5) refugees;
(6) participants in the program of all
				inclusive care for the elderly (PACE);
(7) children and adolescents in out-of-state
				foster care or adoption placements
(8) family planning-only eligible recipients
				and;
(9) residents in an
				intermediate care facility for individuals with intellectual disabilities
				(ICF/IID).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 6 - ELIGIBILITY › Section 8.308.6.10 - SPECIAL SITUATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. HSD
				newborn enrollment criteria.
(1) When a child
				is born to a member enrolled in a MCO, the hospital or other providers will
				complete a MAD form 313 (
notification of birth
) or its
				successor, prior to or at the time of discharge. HSD shall ensure that upon
				receipt of the MAD form 313 and upon completion of the eligibility process, the
				newborn is enrolled into his or her mother's MCO. The newborn is eligible for a
				period of 13 months, starting with the month of his or her birth.
(2) When the newborn's mother is covered by
				health insurance through the New Mexico health insurance exchange and the
				mother's qualified health plan is also a HSD-contracted MCO, HSD will enroll
				the newborn into the mother's MCO as of the month of his or her
				birth.
(3) When the newborn
				member's mother is covered by health insurance through New Mexico health
				insurance exchange and the mother's qualified health plan is not a
				HSD-contracted MCO, HSD shall auto-assign and enroll the newborn in a medicaid
				MCO as of the month of his or her birth.
(4) The newborn member's parent or legal
				guardian will have three months from the first day of the month of birth to
				change the newborn's MCO assignment. After the three-month period, the
				newborn's MCO enrollment may only be changed for cause, as set forth in
				Paragraph (2) of Subsection H of
				8.308.7.9
				NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.3 - 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 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
May 1, 2018, 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 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.6 - 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 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.8 - 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 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.9 - MANAGED CARE ENROLLMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
General:
A medical assistance division (MAD) eligible recipient is
				required to enroll in a HSD managed care organization (MCO) unless he or she
				is:
(1) a Native American who opts into
				managed care. If a Native American is dually eligible or in need of long-term
				care services, he or she is required to enroll in a MCO; or
(2) is in an excluded population. See
				8.200.400 NMAC and 8.308.6 NMAC. Enrollment in a MCO may be the result of the
				eligible recipient's selection of a particular MCO or assignment by HSD. The
				MCO shall accept as a member an eligible recipient in accordance with 42 CFR.
				434.25 and shall not discriminate against, or use any policy or practice that
				has the effect of discrimination against the potential or enrolled member on
				the basis of health status, the need for health care services, or race, color,
				national origin, ancestry, spousal affiliation, sexual orientation or gender
				identity. HSD reserves the right to limit enrollment in a specific
				MCO.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.10 - DISENROLLMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Member
				disenrollment initiated by a MCO
The MCO shall not, under any
				circumstances, disenroll a member. The MCO shall not request disenrollment
				because of a change in the member's health status, because of his or her
				utilization of medical or behavioral health services, his or her diminished
				mental capacity, or uncooperative or disruptive behavior resulting from his or
				her special needs.
B.
Other
				HSD member disenrollment:
A member may be disenrolled from a MCO or may
				lose his or her MAD eligibility if:
(1) he or
				she moves out of the state of New Mexico;
(2) he or she no longer qualifies for a MAP
				category of eligibility or has a change to a MAP category of eligibility that
				is not eligible for managed care enrollment;
(3) he or she requests disenrollment for
				cause, including but not limited to the unavailability of a specific care
				requirement that none of the contracted MCOs are able to deliver and
				disenrollment is approved by HSD;
(4) a member makes a request for
				disenrollment which is denied by HSD, but the denial is overturned in the
				member's HSD administrative hearing final decision; or
(5) HSD imposes a sanction on the MCO that
				warranted disenrollment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.11 - MASS TRANSFER PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
The mass transfer process is initiated when HSD determines
				  that the transfer of MCO members from one MCO to another is in the best
				  interests of the program.
A.
Triggering a mass transfer:
The mass transfer process may be
				triggered by two situations:
(1) a
				maintenance change, such as changes in the MCO identification number or the MCO
				changes its name or other changes that is not relevant to the member and
				services will continue with that MCO; and
(2) a significant change in a MCO's
				contracting status, including but not limited to, the loss of licensure,
				substandard care, fiscal insolvency or significant loss in network providers;
				in such instances, a notice is sent to the member informing him or her of the
				transfer and the opportunity to select a different MCO.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.12 - MEMBER IDENTIFICATION CARD

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Each member shall receive an identification card (ID) that provides his or her
				MCO membership information within 20 calendar days of notification of
				enrollment with the MCO.
B. The MCO
				shall re-issue a member ID card within 10 calendar days of notice if the member
				reports a lost card or if information on the card needs to be
				changed.
C. The MCO shall ensure a
				member understands that the ID card
(1) is
				intended to be used only by the member;
(2) the sharing the member's ID card
				constitutes fraud; and
(3) the
				process of how to report sharing of a member's ID card.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 7 - ENROLLMENT AND DISENROLLMENT › Section 8.308.7.13 - MEDICAID MARKETING GUIDELINES

Current through Register Vol. 35, No. 13, July 16, 2024
HSD shall review and approve the content, comprehension
				  level, and language(s) of all marketing materials directed at a member before
				  use by a MCO. The MCO shall comply with all federal regulations regarding
				  medicare-advantage and medicaid marketing. See 42 CFR. Parts 422,
				  438.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 8 - MEMBER EDUCATION › Section 8.308.8.3 - 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 8 - MEMBER EDUCATION › Section 8.308.8.6 - 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 8 - MEMBER EDUCATION › Section 8.308.8.10 - WRITTEN MEMBER MATERIALS

Current through Register Vol. 35, No. 13, July 16, 2024
A. All
				written materials will be available in English and all languages spoken by
				approximately five percent or more of the MCO's membership, as determined by
				the HSD contracted managed care organization (MCO) or HSD. Upon consent from
				the appropriate native American tribal leadership, the MCO shall make every
				effort when a written form is not in the member's native language to translate
				the form in the member's native language.
B. The MCO is responsible for providing a
				member or potential member with its member handbook and provider directory, as
				requested by a member.
(1) The MCO shall send
				such information to the member within 30 calendar days of receipt of
				notification of enrollment in the MCO.
(2) Thereafter, upon the request from a
				member, the MCO shall send such information within 10 calendar days. The MCO
				shall provide the requestor the option to receive the material in a written or
				electronic form or by citation to be found on the member's MCO's
				website.
(3) On an annual basis,
				the MCO shall notify the member of the availability of updated materials and
				how to obtain such materials.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 8 - MEMBER EDUCATION › Section 8.308.8.11 - MEMBER RIGHTS AND RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall provide each member or the member's authorized
				  representative with written information concerning his or her rights and
				  responsibilities.
A. These include the
				right:
(1) to be treated with respect and with
				due consideration for his or her dignity and privacy;
(2) to receive information on available
				treatment options and alternatives, presented in a manner appropriate to his or
				her condition and ability to understand such information;
(3) to make and have honored his or her
				advance directive that is consistent with state and federal laws;
(4) to receive covered services in a
				nondiscriminatory manner;
(5) to
				participate in decisions regarding his or her health care, including the right
				to refuse treatment;
(6) to be free
				from any form of restraint or seclusion used as a means of coercion,
				discipline, convenience or retaliation, as specified in federal regulations on
				the use of restraints and seclusion;
(7) to request and receive a copy of his or
				her medical records and to request that they be amended or corrected as
				specified in
				45 CFR
				164.524 and 526;
(8) to choose an authorized representative to
				be involved, as appropriate, in making his or her health care
				decisions;
(9) to provide informed
				consent;
(10) to voice grievances
				concerning the care provided by the MCO;
(11) to appeal any action regarding medicaid
				services that the member or his or her authorized representative or authorized
				provider believes is erroneous;
(12) to protect the member, his or her
				authorized representative or authorized provider who uses the grievance,
				appeal, and HSD administrative hearing processes from fear of
				retaliation;
(13) to choose from
				among contracted providers in accordance with his or her MCO's prior
				authorization requirements;
(14) to
				receive information about covered services and how to access these covered
				services, and providers;
(15) to be
				free from harassment by the MCO or its contracted providers in regard to
				contractual disputes between the MCO and the provider;
(16) to participate in understanding physical
				and behavioral health problems and developing mutually agreed-upon treatment
				goals; and
(17) to be assured that
				the MCO complies with any other applicable federal and state laws including:
				Title VI of the Civil Rights Act of 1964 as implemented by regulations in 45
				CFR part 80; the Age Discrimination Act of 1975 as implemented by regulations
				45 CFR part 91; the Rehabilitation Act of 1973; Title IX of the Education
				Amendments of 1972 (regarding education programs and activities); Titles II and
				III of the Americans with Disabilities Act; and section 1557 of the Patient
				Protection and Affordable Care Act.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 8 - MEMBER EDUCATION › Section 8.308.8.12 - MEMBER HEALTH RECORDS

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall provide a member with access to electronic or
				  hard copy versions of his or her personal health records.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 8 - MEMBER EDUCATION › Section 8.308.8.13 - MEMBER HEALTH EDUCATION

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall provide health education to its members. Health
				  education is intended to advise or inform the MCO members about issues related
				  to healthy lifestyles, situations that affect or influence health status,
				  behaviors that affect or influence health status or methods of medical
				  treatment.
A. The MCO shall develop a
				member health education plan that uses classes, individual or group sessions,
				videotapes, written materials, media campaigns and modern technologies (e.g.
				mobile applications and tools).
(1) All
				educational materials shall be provided in a manner and format that is easily
				understood by a member.
(2) The MCO
				shall notify its members of the schedule of educational events and shall post
				such information on its website.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 8 - MEMBER EDUCATION › Section 8.308.8.14 - MEMBER WEBSITE

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall have a member portal on its website that is
				  available to all members and potential members, and contains accurate,
				  up-to-date information about the MCO to include, services provided, the
				  preferred drug list, the provider directory, member handbook, frequently asked
				  questions (FAQs), contact phone numbers and email addresses as set forth in
				  42 CFR
				  438.10. A member or potential member shall
				  have access to the member handbook and provider directory via the website
				  without having to log-in.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 8 - MEMBER EDUCATION › Section 8.308.8.15 - MEMBER TOLL-FREE LINE

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall operate a call center with a toll-free phone
				  line to respond to member questions, concerns, inquiries and complaints from a
				  member and his or her provider. The line shall be equipped to handle calls from
				  an individual with limited English proficiency, as well as calls from a member
				  who is hearing impaired. It should be staffed 24 hours a day, seven days a
				  week, with qualified nurses to triage urgent care and emergency calls from a
				  member, and when necessary, to facilitate the transfer of such calls to a care
				  coordinator.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 8 - MEMBER EDUCATION › Section 8.308.8.16 - MEMBER ADVISORY BOARD

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall convene advisory boards that meet quarterly
				  and are representative of its membership. The advisory board shall advise the
				  MCO on issues concerning service delivery, quality of its covered services, and
				  other member issues as needed or as directed by HSD.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.3 - 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.