New Mexico Register / Volume XXXIII, Issue 7
/ April 5, 2022
This is an
amendment to 8.291.400 NMAC, Sections 7, 8, 12, 13 and 14, effective 4/5/2022.
8.291.400.7 DEFINITIONS:
A. Action: an approval, termination, suspension, or reduction
of medicaid eligibility or a reduction in the level of benefits and services,
including a determination of income for the purposes of imposing any premiums,
enrollment fees, or cost-sharing. It
also means determinations made by skilled nursing facilities and nursing
facilities to transfer or discharge residents and adverse determination made by
a state with regard to the preadmission screening and resident review
requirements.
B. Advance payments
of the premium tax credit (APTC):
payment of the tax credits specified in Section 36B of the Internal
Revenue Code which are provided on an advance basis to an eligible individual
enrolled in a qualified health plan through an exchange.
C. Affordable Care
Act (ACA): the Patient Protection and
Affordable Care Act of 2010 (Public Law 111-148), as amended by the Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152) and the Three
Percent Withholding Repeal and Job Creation Act (Public Law 112-56).
D. Affordable
insurance exchanges (exchanges): a
governmental agency or non-profit entity that meets the applicable requirements
and makes qualified health plans available to qualified individuals and
qualified employers. Unless otherwise
identified, this term refers to state exchanges, regional exchanges, subsidiary
exchanges, and a federally-facilitated exchange.
E. Agency: the single state agency designated or
established by a state to administer or supervise the administration of the
medicaid state plan. This designation
includes a certification by the state attorney general, citing the legal
authority for the single state agency to make rules and regulations that it
follows in administering the plan or that are binding upon local agencies that
administer the plan.
F. Appeal
record: the appeal decision, all papers
and requests filed in the proceeding, and if a hearing was held, the transcript
or recording of hearing testimony or an official report containing the
substance of what happened at the hearing, and any exhibits introduced at the
hearing.
G. Appeal
request: a clear expression, either
verbally or in writing, by an applicant, enrollee, employer, or small business
employer or employee to have any eligibility determination or redetermination
contained in a notice issued reviewed by an appeals entity.
H. Appeals
entity: a body designated to hear
appeals of eligibility determinations or redeterminations contained in notices,
or notices issued in accordance with future guidance on exemptions.
I. Appeals
decision: a decision made by a hearing
officer adjudicating a fair hearing, including by a hearing officer employed by
an exchange appeals entity to which the agency has delegated authority to
conduct such hearings.
J. Applicable
modified adjusted gross income (MAGI) standard:
the income standard for each category of ACA eligibility.
K. Application: the single streamlined application required
by ACA and other medicaid applications used by the agency.
L. Authorized
representative: the agency must permit
applicants and beneficiaries to designate an individual or organization to act
responsibly on their behalf in assisting with the individual’s application and
renewal of eligibility and other ongoing communications with the agency.
(1) Such
a designation must be in writing including the applicant’s signature, and must
be permitted at the time of application and at other times. Legal documentation of authority to act on
behalf of an applicant or beneficiary under state law, such as a court order
establishing legal guardianship or a power of attorney, shall serve in the
place of written authorization by the applicant or beneficiary.
(2) Representatives
may be authorized to:
(a) sign
an application on the applicant’s behalf;
(b) complete
and submit a renewal form;
(c) receive
copies of the applicant or beneficiary’s notices and other communications from
the agency; and
(d) act
on behalf of the applicant or beneficiary in all other matters with the agency.
(3) The
power to act as an authorized representative is valid until the applicant or
beneficiary modifies the authorization or notifies the agency that the
representative is no longer authorized to act on [his or her] their
behalf, or the authorized representative informs the agency that [he or she
is] they are no longer acting in such capacity, or there is a change
in the legal authority upon which the individual’s or organization’s authority
was based. Such notice must be in
writing and should include the applicant or authorized representative’s
signature as appropriate.
(4) The
authorized representative is responsible for fulfilling all responsibilities
encompassed within the scope of the authorized representation to the same
extent as the individual [he or she represents] they represent,
and must agree to maintain, or be legally bound to maintain, the
confidentiality of any information regarding the applicant or beneficiary
provided by the agency.
(5) As
a condition of serving as an authorized representative, a provider, staff
member or volunteer of an organization must sign an agreement that [he or
she] they will adhere to the regulations relating to confidentiality
(relating to the prohibition against reassignment of provider claims as
appropriate for a health facility or an organization acting on the facility’s
behalf), as well as other relevant state and federal laws concerning conflicts
of interest and confidentiality of information.
M. Beneficiary: an individual who has been determined
eligible and is currently receiving medicaid.
N. Citizenship: a national of the United States means a
citizen of the United States or a person who, though not a citizen of the
United States, owes permanent allegiance to the United States.
O. Code: the internal revenue code.
P. Coordinated
content: information included in an
eligibility notice regarding the transfer of the individual’s or households
electronic account to another insurance affordability program for a
determination of eligibility.
Q. Current
beneficiaries: individuals who have been
determined financially eligible for medicaid using MAGI-based methods.
R. Dependent
child: an un-emancipated child who is
under the age of 19.
S. Documentary evidence: a photocopy facsimile, scanned or other copy
of a document must be accepted to the same extent as an original document.
T. Electronic
account: an electronic file that
includes all information collected and generated by the state regarding each
individual’s medicaid eligibility and enrollment, including all documentation
required to support the agency’s decision on the case.
U. Expedited
appeals: the agency must establish and
maintain an expedited review process for hearings when an individual requests
or a provider requests, or supports the individual’s request, that the time
otherwise permitted for a hearing could jeopardize the individual’s life or
health or ability to attain, maintain, or regain maximum function. If the agency denies a request for an
expedited appeal, it must use the standard appeal timeframe.
V. Family
size: the number of persons counted as
members of an individual’s household. In
the case of determining the family size of a pregnant [woman, the pregnant
woman is counted as herself plus the number of children she is expected to
deliver. In the case of determining the
family size of other individuals who have a pregnant woman in their household,
the pregnant woman is counted as herself plus the number of children she is
expected to deliver.] individual, the pregnant individual is counted as
themselves plus the number of children they are expected to deliver. In the case of determining the family size of
other individuals who have a pregnant individual in their household, the
pregnant individual is counted as themselves plus the number of children they
are expected to deliver.
W. Insurance
affordability program: a state medicaid
program under Title XIX of the act, state children’s health insurance program
(CHIP) under Title XXI of the act, a state basic health program established
under ACA and coverage in a qualified health plan through the exchange with
cost-sharing reductions established under Section 1402 of ACA.
X. MAGI-based
income: For the purposes of this
section, MAGI-based income means income calculated using the same financial
methodologies used to determine a modified adjusted gross income as defined in
Section 36B(d)(2) (B) of the Internal Revenue Code, with the certain
exceptions.
Y. Managed care organization (MCO): an organization licensed or authorized
through an agreement among state entities to manage, coordinate and receive
payment for the delivery of specified services to medicaid eligible members.
Z. Modified
adjusted gross income (MAGI): has the
meaning of 26 CFR 1.36B-1 Section (2).
AA. Non-applicant: an individual who is not seeking an
eligibility determination for [himself or herself] themselves and
is included in an applicant’s or beneficiary’s household to determine
eligibility for such applicant or beneficiary.
BB. Non-citizen: [has
the same meaning as the term “alien” and includes any individual] an individual who is not a citizen
or national of the United States (8 USC 1101(a)(22).
CC. Parent
caretaker: a relative of a dependent
child by blood, adoption, or marriage with whom the child is living, who
assumes primary responsibility for the child’s care (as may, but is not
required to, be indicated by claiming the child as a tax dependent for federal
income tax purposes) and who is one of the following:
(1) the
child’s father, mother, grandfather, grandmother, brother, sister, stepfather,
stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or
niece;
(2) the
spouse of such parent or relative, even after the marriage is terminated by
death or divorce; or
(3) other
relatives within the fifth degree of relationship (42 CFR 435.4).
DD. Patient Protection and Affordable Care
Act (PPACA): also known as the Affordable Care Act (ACA)
and is the health reform legislation passed by the 111th congress and signed
into law in March of 2010.
EE. Tax
dependent: has the same meaning as the
term “dependent” under Section 152 of the Internal Revenue Code, as an
individual for whom another individual claims a deduction for a personal
exemption under Section 151 of the Internal Revenue Code for a taxable year.
[8.291.400.7 NMAC -
Rp, 8.291.400.7 NMAC, 10/1/2017; A, 4/5/2022]
8.291.400.8 [RESERVED] MISSION: 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.
[8.291.400.8 NMAC -
Rp, 8.291.400.8 NMAC, 10/1/2017; A, 4/5/2022]
8.291.400.12 REPORTING REQUIREMENTS: A
medicaid eligible recipient is required to report certain changes which might
affect [his or her] their eligibility to ISD within 10 calendar
days from the date the change occurred.
A timely change that is reported within 10 calendar days that may result
in a more beneficial medicaid eligibility category shall be evaluated in the
month the change occurred. An untimely
change that is reported after 10 calendar days that may result in a more
beneficial medicaid eligibility category shall be evaluated in the month the
change was reported. A reported change
that does not result in the same or a more beneficial medicaid category is
considered an adverse action and is applied prospectively in accordance with
8.100.180.10 NMAC. See 8.100.110.9 NMAC
for the various ways applicants and recipients can submit changes to the HSD. The following changes must be reported to
ISD:
A. living arrangements
or change of address: any change in
where an individual lives or receives mail must be reported;
B. household
size: any change in the household size
must be reported, this includes the death of an individual included in the
assistance unit or budget group;
C. enumeration: any new social security number must be
reported; or
D. income: any increase or decrease in the amount of
income or change in the source of income must be reported.
[8.291.400.12 NMAC -
Rp, 8.291.400.12 NMAC, 10/1/2017; A, 4/5/2022]
8.291.400.13 PRESUMPTIVE ELIGIBILITY:
Presumptive eligibility (PE) provides medicaid benefits under one of the
eligible groups outlined in Subsection B of 8.291.400.10 NMAC, starting with
the date of the PE determination and ending with the last day of the following
month or, if an ongoing application is submitted at the time the PE is
granted or at any time during the approved PE period, the PE will remain open
until the ongoing application is approved or denied.
[ A. Only one
presumptive eligibility period is allowed per pregnancy or per 12 month period
for other ACA related categories.
B. Determinations
can be made only by individuals employed by eligible entities and certified as
presumptive eligibility PE determiners by the medical assistance division. Determiners must notify the medical
assistance division (MAD) claims processing contractor of the determination
within 24 hours of the determination of presumptive eligibility.
(1) Processing PE information: MAD authorizes certain providers to make PE
determinations based on the qualified entity.
The provider must notify MAD through an established procedure of the
determination within 24 hours of the determination of presumptive eligibility.
(2) PE:
The PE provider must process both presumptive eligibility as well as an
application for medical assistance.
(3) Provider eligibility: Entities who may participate must be:
(a) a
qualified hospital that participates as a provider under the medicaid state
plan or a medicaid 1115 demonstration, notifies the medicaid agency of its
election to make presumptive eligibility determinations and agrees to make PE
determinations consistent with state policies and procedures; or
(b) a
qualified hospital that has as not been disqualified by the medicaid agency for
failure to make PE determinations in accordance with applicable state policies
and procedures or for failure to meet any standards that may have been
established by the medicaid agency; or
(c) a
federally qualified health center (FQHC), an Indian health service (IHS) facility, a department of
health (DOH) clinic, a school, a children, youth and families department (CYFD)
child care bureau staff member, a primary care provider who is contracted with
at least one HSD contracted MCO, or a head start agency; or
(d) other
entities HSD has determined as an eligible presumptive participant.
C. PE approval
limitations:
(1) all
MAD authorized PE determiners can approve PE for children and pregnant women
ACA categories;
(2) hospitals
opting to do PE can approve PE for all ACA related categories; and
(3) correctional
facilities (state prisons and county jails) and health facilities operated by
the Indian health Service, a tribe, or tribal organization, or an urban Indian
organization can approve PE for the other adult, parent caretaker, pregnant
women, pregnancy-related services, and children under 19 years of age ACA
categories.
D. Children’s health insurance program (CHIP): to be eligible for CHIP, the child cannot
have other health insurance coverage.
E. A PE provider
must ensure that a signed application for medicaid coverage is submitted to the
ISD office within 10 days.
F. For
pregnant women, PE allows medicaid payment for ambulatory prenatal services
furnished to a pregnant woman while her application for medicaid is being
processed. Only one presumptive
eligibility period is allowed per pregnancy.
A pregnant woman can receive ambulatory prenatal care from the date of
the PE determination until the end of the month following the month the
determination was made.
(1) For
PE, an approved PE provider must accept self attestation of pregnancy.
(2) The
needs and income of the unborn child(ren) are considered when determining the
woman’s countable family size.]
A. Only one PE
approval is allowed per pregnancy or per 12-month period for other ACA related
categories.
B. Determinations
can only be made by individuals employed by eligible entities and certified as
presumptive eligibility determiners (PEDs) by the medical assistance division
(MAD).
(1) Processing PE information: PEDs must notify MAD within 24 hours of the
determination of presumptive eligibility.
(2) PE:
The PED must process the presumptive eligibility and encourage clients
to submit an ongoing application for medicaid eligibility. If the client elects to do so, the PED must
assist the client with the submission of an application for medical assistance.
(3) Provider eligibility: Entities who may participate in the PE
program must be:
(a) a
qualified hospital that participates as a provider under the medicaid state
plan or a medicaid 1115 demonstration who notifies the medicaid agency of its
election to make presumptive eligibility determinations and agrees to make PE
determinations consistent with state policies and procedures; or
(b) an
entity or provider that has not been disqualified by the medicaid agency for failure
to make PE determinations in accordance with applicable state policies and
procedures or for failure to meet any standards that may have been established
by the medicaid agency; or
(c) a
federally qualified health center (FQHC), an Indian health service (IHS)
facility, a state of New Mexico agency, a school, or a head start agency or a
primary care provider who is contracted with at least one HSD contracted MCO;
or
(d) other
entities HSD has determined as an eligible presumptive participant.
C. PE approval
limitations:
(1) all
MAD authorized PE determiners can approve PE for children and pregnant women
ACA categories;
(2) hospitals
opting to participate in the PE program and correctional facilities (state
prisons and county jails), health facilities operated by the Indian health
service, a tribe, or tribal organization or an urban Indian organization can
approve PE for all ACA related categories.
E. A
pregnant individual who has been approved for PE can receive ambulatory
prenatal care during the PE approval period as defined in 8.291.400.13 NMAC.
(1) For
PE, an approved PED must accept self-attestation of pregnancy.
(2) The
needs and income of the unborn child(ren) are considered when determining the
woman’s countable family size.
[8.291.400.13 NMAC -
Rp, 8.291.400.13 NMAC, 10/1/2017; A, 4/5/2022]
8.291.400.14 PREGNANT
INDIVIDUALS ELIGIBLE FOR EXTENDED OR CONTINUOUS ELIGIBILITY (42 CFR 435.170):
A. Extended eligibility for pregnant
individuals: For a pregnant individual
who was eligible and enrolled for mandatory or optional coverage under the
state plan on the date their pregnancy ends (regardless of the reason the
pregnancy ends), HSD provides full medicaid coverage through the last day of
the month in which the 12-month postpartum period ends.
B. Continuous eligibility for pregnant
individuals: For a pregnant individual
who was eligible and enrolled for mandatory or optional coverage under the
state plan and who, because of a change in circumstance (e.g., income,
household, composition, aging out etc.), will not otherwise remain eligible,
HSD provides full medicaid coverage through the last day of the month in which
the 12-month postpartum period ends.
(1) The
following populations are provided continuous eligibility effective April 1,
2022:
(a) Current medicaid recipients who are
pregnant as of April 1, 2022 or who enroll based on pregnancy or become
pregnant after April 1, 2022.
(b) Current medicaid recipients who are
receiving medicaid while pregnant and who are no longer pregnant as of April 1,
2022, but who are still within a 12-month postpartum period; and
(c) Individuals who apply for medicaid
after their pregnancy ends, who received medicaid-covered services while
pregnant on or after April 1, 2022 if such services were received during an
approved period of retroactive eligibility.
(2) The following applies to certain categories or
individuals:
(a) An individual approved on the other
adult category who becomes pregnant may remain on the adult category and
receive services under the alternative benefit plan (ABP). The ABP is considered full benefits for the
purpose of the 12-month extended postpartum period. An individual on the other adult category who
becomes pregnant may also transition to another full coverage medicaid category
such as pregnant women or parent/caretaker and will remain eligible until their
12-month postpartum period expires.
(b) Children turning age 19 aging out of
a children’s medicaid category will remain on a children’s medicaid category
until their 12-month postpartum period expires.
(c) An individual covered on the
parent/caretaker category during a 12-month postpartum period and who has
increased earnings or spousal support above the parent/caretaker category limit
will remain on the parent/caretaker category until their 12-month postpartum
period expires and then can transition to a four or 12-month transitional
medical assistance period.
(d) An individual who becomes pregnant
during the 12-month postpartum period is entitled to 12-months continuous
coverage through the end of the second pregnancy and the 12-month postpartum
period following.
(e) The extended 12-month postpartum
period applies to individuals receiving medicaid who are lawfully residing
children under age 21 and pregnant individuals referred to as “CHIPRA 214”.
C. Renewals: Medicaid renewals are conducted at the end of
the individual’s 12-month postpartum period.
Individuals remain enrolled in the eligibility group in which the
individual was enrolled during pregnancy through the end of the 12-month
postpartum period as described in Subsection C of 8.291.400.14 NMAC.
D. There is not extended or continuous medicaid eligibility for a pregnant
individual covered during a presumptive eligibility period under section 1920
of the ACT.
E. An individual’s eligibility may not be terminated during
a continuous eligibility period, regardless of any changes in circumstances,
unless:
(1) the individual or their
representative requests a voluntary termination of eligibility;
(2) the individual ceases to be a
resident of New Mexico;
(3) eligibility was determined
incorrectly at the most recent determination or redetermination of eligibility
because of HSD error or fraud, abuse, or perjury attributed to the individual;
or
(4) the individual dies.
[8.291.400.14 NMAC - N, 4/5/2022]