TITLE 8 SOCIAL SERVICES
CHAPTER 200 MEDICAID ELIGIBILITY - GENERAL RECIPIENT RULES
PART 430 RECIPIENT RIGHTS AND RESPONSIBILITIES
8.200.430.1 ISSUING
AGENCY: Health Care Authority (HCA).
[8.200.430.1 NMAC -
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8.200.430.2 SCOPE: The
rule applies to the general public.
[8.200.430.2 NMAC -
Rp, 8.200.430.2 NMAC, 1/1/2014]
8.200.430.3 STATUTORY
AUTHORITY: 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.
[8.200.430.3 NMAC -
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8.200.430.4 DURATION: Permanent.
[8.200.430.4 NMAC -
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8.200.430.5 EFFECTIVE
DATE: January 1, 2014, unless a later date is cited
at the end of a section.
[8.200.430.5 NMAC -
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8.200.430.6 OBJECTIVE: The
objective of this rule is to provide specific instructions when determining
eligibility for the medicaid program and other health
care programs. Generally, applicable
eligibility rules are detailed in the medical assistance division (MAD)
eligibility policy manual, specifically 8.200.400 NMAC, General Medicaid Eligibility.
Processes for establishing and maintaining MAD eligibility are detailed
in the income support division (ISD) general provisions 8.100 NMAC, General Provisions for Public Assistance
Programs.
[8.200.430.6 NMAC -
Rp, 8.200.430.6 NMAC, 1/1/2014]
8.200.430.7 DEFINITIONS: [RESERVED]
8.200.430.8 [RESERVED]
[8.200.430.8 NMAC - N, 1/1/2014; A, 10/1/2017]
8.200.430.9 RECIPIENT RIGHTS AND RESPONSIBILITIES:
A. An individual has
the right to apply for medicaid and other health care
programs HCA administers regardless of whether it appears they may be eligible.
(1) Income
support division (ISD) determines eligibility for the medical assistance
division’s medical assistance programs (MAP), unless otherwise determined by
another entity as stated in 8.200.400 NMAC.
A decision shall be made promptly
on applications in accordance with the timeliness standards set forth in
8.100.130 NMAC.
(2) Individuals
who might be eligible for supplemental security income (SSI) are referred to
the social security administration (SSA) office to apply.
B. Application: A paper or electronic
application is required from the applicant, an authorized representative, or,
if the applicant is incompetent or incapacitated, someone acting responsibly
for the applicant. The applicant may complete a joint MAP, cash
assistance, supplemental nutrition assistance program (SNAP) and low income
home energy assistance (LIHEAP) application or a MAP-only application.
(1) The
following do not require an application unless a re-determination is due in
that month or the following month, as applicable:
(a) switching
from one of the medical assistance for women, children (MAWC) and families MAP
categories to another;
(b) switching
between medicaid and refugee medical assistance; and
(c) switching
to or from one of the long term care medicaid
categories.
(2) Medicare
savings programs (MSP):
(a) A
MAP eligible recipient receiving full benefits is automatically deemed eligible
for MSP when they receive free medicare Part-A
hospital insurance; the eligible recipient does not have to apply for medicare MSP;
(b) When
an individual is not eligible for free medicare Part
A hospital insurance, a separate application for the MAP qualified medicare beneficiary (QMB) eligibility category 040 is
required. Individuals must apply for medicare
Part A with the SSA. This is called,
“conditional Part A” because they will receive medicare
Part A on the condition that the MAP QMB category of eligibility is approved. When
QMB is approved, the cost of the premium for Part A will be covered by MAD.
C. Responsibility in the application or
recertification process: The applicant or the re-determining eligible
recipient is responsible for providing verification of eligibility. Refer to 8.100.130 NMAC.
(1) An
applicant or an eligible recipient's failure to provide necessary verification
results in MAP ineligibility.
(2) An
applicant or a re-determining eligible recipient must give HCA permission to
contact other individuals, agencies, or sources of information which are
necessary to establish eligibility.
[8.200.430.9 NMAC -
Rp, 8.200.430.9 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.10 FREEDOM OF CHOICE: Except
when specifically waived from MAD, an eligible recipient has the freedom to
obtain physical and behavioral health services from a MAD provider of their choice.
[8.200.430.10 NMAC -
Rp, 8.200.430.10 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.11 RELEASE OF INFORMATION: By
signing the MAP application, an applicant or a re-determining eligible
recipient gives HCA explicit consent to release information to applicable state
or federal agencies, physical or behavioral health providers, or an HCA designee
when the information is needed to provide, monitor, or approve MAD services. Physical and behavioral health information is
confidential and is subject to the standards for confidentiality per 8.300.11
NMAC.
[8.200.430.11 NMAC -
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8.200.430.12 RIGHT TO HEARING: An
applicant or an eligible recipient is entitled to adequate notice of a HCA adverse action regarding their termination or
re-categorization of their MAP category of eligibility. The applicant or re-determining eligible
recipient has specific rights and responsibilities when requesting a HCA administrative hearing. A HCA administrative
hearing affords the applicant or re-determining eligible recipient the
opportunity to have an impartial review of these decisions. See 8.352.2, 8.100.180 and 8.100.970 NMAC for
a detailed description of these rights, responsibilities and the HCA administrative
hearing process. 8.352.2 NMAC further
details the rights, responsibilities and the HCA administrative hearing process
for other adverse actions MAD, its utilization review contractor or a HCA contracted managed care organization (MCO) may
initiate (42 CFR Section 431.220(a)(1)(2)).
[8.200.430.12 NMAC -
Rp, 8.200.430.12 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.13 ASSIGNMENT OF SUPPORT: As a
condition of MAP eligibility, HCA requires an applicant or a re-determining
eligible recipient to assign their medical care support rights to HCA for
medical support and any third party payments.
The assignment authorizes HCA to pursue and make recoveries from liable
third parties (42 CFR 433.146; Subsection G of 27-2-28 NMSA 1978.
A. Assigning medical
support rights: The
assignment to HCA of an eligible recipient’s rights to medical support and
payments occurs automatically under New Mexico law when the applicant or the re-determining
eligible recipient signs the application.
B. Third party liability (TPL): This section describes HCA’s responsibility to
identify and collect from primarily responsible third parties and the eligible
recipient’s responsibility to cooperate with HCA to uncover such payments. MAD is the payer of last resort. If other third party resources are available,
these health care resources must be used before MAD makes a
reimbursement. As a condition of MAP
eligibility, an applicant assigns their rights to physical and behavioral
health support and payments to HCA and promises to cooperate in identifying, pursuing,
and collecting payments from these resources.
Third party resources include the gross recovery by eligible recipient,
including personal injury protection benefits, before any reduction in
attorney’s fees or costs, obtained through settlement or verdict, for personal
injury negligence or intentional tort claims or actions, up to the full amount
of MAD payments for treatment of injuries causally related to the occurrence
that is the subject of the claim or action.
(1) Required TPL information: During the
initial determination or re-determination of eligibility for MAP enrollment,
ISD must obtain information about TPL from either the applicant or the re-determining
eligible recipient.
(a) HCA
is required to take all reasonable measures to determine the legal liability of
third parties, including health insurers in paying for the physical and
behavioral health services furnished to an eligible recipient (42 CFR
433.138(a)).
(b) HCA
uses the information collected at the time of determination in
order for MAD to pursue claims against third parties.
(2) Availability of health insurance: If
an applicant or an eligible recipient has health insurance, the applicant or
the eligible recipient shall notify ISD.
ISD must collect all relevant information, including name and address of
the insurance company; individuals covered by the policy, effective dates,
covered services, and appropriate policy numbers.
(a) An
applicant or an eligible recipient with health insurance coverage or coverage
by a health maintenance organization (HMO) or other managed care plan (plan)
must be given a copy of the TPL recipient information letter.
(b) If
there is an absent parent, ISD may request the absent parent's name and social
security number (SSN).
(c) ISD
must determine if an absent parent, relative, applicant or any member of the
household is employed and has health insurance coverage.
(3) Eligible recipients with health insurance
coverage: An applicant or an eligible recipient must inform their MAD
providers of their TPL. An applicant or
an eligible recipient must report changes to or terminations of insurance
coverage to ISD. If an applicant or an
eligible recipient has health coverage through an HMO or plan, payment from MAD
is limited to applicable copayments required under the HMO or plan and to MAD
covered services documented in writing as exclusions by the HMO or plan.
(a) If
the HMO or plan uses a drug formulary, the medical director of the HMO or plan
must sign and attach a written certification for each drug claim to document
that a pharmaceutical product is not covered by the HMO or plan. The signature is a certification that the HMO
or plan drug formulary does not contain a therapeutic equivalent that
adequately treats the physical or behavioral health condition of the HMO or
plan subscriber.
(b) Physical
and behavioral health services not included in the HMO or plan are covered by
MAD only after review of the documentation and on approval by MAD.
(c) An
applicant or an eligible recipient covered by an HMO or plan is responsible for
payment of medical services obtained outside the HMO or plan and for medical
services obtained without complying with the rules or policies of the HMO or
plan.
(d) An
applicant or an eligible recipient living outside an HMO or plan coverage area
may request a waiver of the requirement to use HMO or plan providers and
services. The applicant or the eligible
recipient for whom a coverage waiver is approved by MAD may receive
reimbursement for expenses which allow them to travel to an HMO or plan
participating provider, even when the provider is not located near the
applicant or the eligible recipient's residence.
(4) Potential health care resources: ISD
must evaluate the presence of a TPL source if certain factors are identified
during the MAD eligibility interview.
(a) When the age of the applicant or the eligible
recipient is over 65 years old medicare must be explored.
A student, especially a college student, may have health or accident
insurance through their school.
(b) An
application on behalf of deceased individual must be examined for "last
illness" coverage through a life insurance policy.
(c) Certain
specific income sources are indicators of possible TPL which include:
(i) railroad retirement benefits and
social security retirement or disability benefits indicating eligibility for
Title XVIII (medicare) benefits;
(ii) workers'
compensation (WC) benefits paid to employees who suffer an injury or accident
caused by conditions arising from employment; these benefits may compensate
employees for physical and behavioral health expenses and lost income; payments
for physical and behavioral health expenses may be made as physical and
behavioral health bills are incurred or as a lump sum award;
(iii) black
lung benefits payable under the coal mine workers' compensation program,
administered by the federal department of labor (DOL), can produce benefits
similar to railroad retirement benefits if the treatment for illness is related
to the diagnosis of pneumoconiosis; beneficiaries are reimbursed only if
services are rendered by specific providers, authorized by the DOL; black lung
payments are made monthly and physical and behavioral health expenses are paid
as they are incurred; and
(iv) Title
IV-D support payments or financial support payments from an absent parent may
indicate the potential for physical and behavioral health support; if a
custodial party does not have health insurance that meets a minimum standard,
the court in a divorce, separation or custody and support proceeding may order
the parent(s) with the obligation of support to purchase insurance for the
eligible recipient child (45 CFR 303.31(b)(1); Paragraph (1) of Subsection A of
Section 40-4C-4 NMSA 1978; insurance can be obtained through the parent's
employer or union (Paragraph (2) of Subsection A of Section 40-4C-4 NMSA 1978;
parents may be ordered to pay all or a portion of the physical and behavioral
health expenses; for purposes of physical l and behavioral health support, the
minimum standards of acceptable coverage, deductibles, coinsurance, lifetime
benefits, out-of-pocket expenses, co-payments, and plan requirements are the
minimum standards of health insurance policies and managed care plans
established for small businesses in New Mexico; see New Mexico insurance code.
(d) An
applicant or an eligible recipient has
earned income: Earned income may indicate physical, behavioral health
and health insurance made available by an employer.
(e) Work history or military services:
Work history may indicate eligibility for other cash and physical and
behavioral benefits. Previous military
service suggests the potential for veterans administration (VA) or department
of defense (DOD) health care, including the civilian health and the medical
program of the United States (CHAMPUS), for individuals who reside within a
40-mile radius of a military health care facility. An applicant or an eligible recipient who is
eligible for DOD health care must obtain certification of non-availability of
medical services from the base health benefits advisor in
order to be eligible for CHAMPUS.
(f) An applicant or an eligible recipient's
expenses show insurance premium payments: Monthly expense information
may show that the applicant or the eligible recipient pays private insurance
premiums or is enrolled in an HMO or plan.
(g) The applicant or the eligible recipient has a
disability: Disability information contained in applications or brought
up during interviews may indicate casualties or accidents involving legally
responsible third parties.
(h) The applicant or the eligible recipient has a
chronic disease: Individuals with
chronic renal disease are probably entitled to medicare. Applications for social security disability
may be indicative of medicare coverage.
(5) Communicating TPL information: Information concerning health insurance or
health plans is collected and transmitted to MAD by ISD, child support
enforcement division (CSED), SSA, and the children, youth and families
department (CYFD).
[8.200.430.13 NMAC -
Rp, 8.200.430.13 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.14 ELIGIBLE RECIPIENT RESPONSIBILITY TO
COOPERATE WITH ASSIGNMENT OF SUPPORT RIGHTS:
A. Cooperation: As a condition of MAP eligibility, an
applicant or an eligible recipient must cooperate with HCA to:
(1) obtain
physical and behavioral health support and payments for them and other
individuals for whom they can legally assign rights;
(2) pursue
liable third parties by identifying individuals and providing information to HCA;
(3) cooperate
with CSED to establish paternity and medical support as appropriate, see
8.50.105.12 NMAC;
(4) appear
at a state or local office designated by HCA to give information or evidence
relevant to the case, appear as a witness at a court or other proceeding or
give information or attest to lack of information, under penalty of perjury;
(5) refund
HCA any money received for physical or behavioral health care that has already
been paid; this includes payments received from insurance companies, personal
injury settlements, and any other liable third party; and
(6) respond to the trauma inquiry letter
that is mailed to an eligible
recipient (42 CFR 433.138(4); the letter asks an eligible recipient to provide
more information about possible accidents, causes of accidents, and whether legal
counsel has been obtained (42 CFR 433.147; 45 CFR 232.42, 232.43; Paragraph (3)
of Subsection G of Section 27-2-28 NMSA 1978.
B. Good cause waiver of cooperation: The
requirements for cooperation may be waived by HCA if it decides that the
applicant or the eligible recipient has good cause for refusing to cooperate. Waivers can be obtained for cooperating with
CSED. The applicant or the eligible
recipient should request a good cause waiver from CSED per 8.50.105.14 NMAC.
C. Penalties for failure to cooperate:
(1) When
the parent, the specified relative or legal guardian fails or refuses to
cooperate, the parent or specified relative will not be eligible for MAD
services. The eligible recipient child
maintains MAP eligibility provided all other eligibility criteria are met.
(2) When
the parent or the specified relative fails or refuses to refund payments
received from insurance or other settlement sources, such as personal injury
case awards, they are not eligible for MAD services for one year and until full
restitution has been made to HCA. The
eligible recipient child maintains MAP eligibility provided all other
eligibility criteria are met.
[8.200.430.14 NMAC -
Rp, 8.200.430.14 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.15 ELIGIBLE RECIPIENT RESPONSIBILITY TO GIVE PROVIDER PROPER IDENTIFICATION AND
NOTICE OF ELIGIBILITY CHANGES:
A. An eligible
recipient is responsible for presenting a current MAP eligibility card and
evidence of any other health insurance to a MAD provider each time service is
requested.
(1) An
eligible recipient is responsible for any financial liability incurred if they fail
to furnish current MAP eligibility identification before the receipt of a
service and as a result the provider fails to adhere to MAD rules, such as a
failure to request prior approval. If
this omission occurs, the settlement of claims for services is between the
eligible recipient and the provider. An
individual is financially responsible for services received if they were not
eligible for MAD services on the date services are furnished.
(2) When
a provider bills MAD and the claim is denied, the provider cannot bill the
eligible recipient. Exceptions exist for
denials caused by MAP ineligibility or by an eligible recipient's failure to
furnish MAP identification in a timely manner.
(3) If
an eligible recipient fails to notify the provider that they have received
services that are limited by time or amount, the eligible recipient is
responsible for payment of the service prior to rendering the service if the
provider made reasonable efforts to verify whether the eligible recipient has
already received services.
B. Notification of providers following
retroactive eligibility determinations:
If an eligibility determination is made, the eligible recipient is
responsible for notifying MAD providers of this eligibility determination. When
an individual receives retro MAP eligibility, the now-eligible recipient must
notify all of their MAD providers of their change of
eligibility. If the eligible recipient fails to notify the
provider and the provider can no longer file a claim for reimbursement, the
eligible recipient becomes the responsible payer for those services.
C. Notification if an eligible recipient has
private insurance: If an eligible
recipient is covered under a private health insurance policy or health plan, they
are required to inform their MAD providers of the private health coverage,
including applicable policy numbers and special claim forms.
[8.200.430.15 NMAC -
Rp, 8.200.430.15 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.16 ELIGIBLE RECIPIENT FINANCIAL
RESPONSIBILITIES:
A. A MAD provider
agrees to accept the amount paid as payment in full. A
provider cannot bill an eligible recipient for any unpaid portion of the bill
(balance billing) or for a claim that is not paid because of a provider
administrative error or failure of multiple providers to communicate
eligibility information.
(1) An
eligible recipient is responsible for any financial liability incurred if they fail
to furnish current MAP eligibility identification before the receipt of a MAP
service and as a result the provider fails to adhere to MAD reimbursement
rules, such as a failure to request prior approval. If
this omission occurs, the settlement of claims for services is between the
eligible recipient and the MAP provider.
An individual is financially
responsible for services received if they were not eligible for MAD services on
the date services are furnished.
(2) When
a provider bills MAD and the claim is denied, the provider cannot bill the
eligible recipient. Exceptions exist for denials caused by MAP
ineligibility or by an eligible recipient's failure to furnish MAP
identification at the time of service.
(3) If
an eligible recipient fails to notify a provider that they have received
services that are limited by time or amount, the eligible recipient is
responsible to pay for services if, before furnishing the services, the
provider makes reasonable efforts to verify whether the eligible recipient has
already received services.
B. Failure of an eligible recipient to follow their
privately held health insurance carrier’s requirements: An eligible
recipient must be aware of the physician, pharmacy, hospital, and other
providers who participate in their HMO or other managed care plan. An eligible recipient is responsible for
payment for services if they use a provider who is not a participant in their
plan or if they receive any services without complying with the rules,
policies, and procedures of their plan.
C. Other eligible recipient payment
responsibilities: If all the following conditions are met before a MAD
service is furnished, the eligible recipient can be billed directly by a MAD
provider for services and is liable for payment:
(1) the
eligible recipient is advised by a provider that the particular
service is not covered by MAD or is advised by a provider that they are
not a MAD provider;
(2) the
eligible recipient is informed by a provider of the necessity, options, and
charges for the services and the option of going to another provider who is a
MAD provider; and
(3) the
eligible recipient agrees in writing to have the service provided with full
knowledge that they are financially responsible for the payment.
[8.200.430.16 NMAC -
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11/1/2024]
8.200.430.17 RESTITUTION:
A. A MAP eligible
recipient must return overpayments or medical payments received from liable
third parties to the applicable medical service provider or to MAD. If payments are not returned or received,
recoupment proceedings against the eligible recipient will be initiated.
B. The restitution
bureau of HCA is responsible for the tracking and collection of overpayments
made to MAP eligible recipients, vendors, and MAD providers. See Section OIG-940, RESTITUTIONS. The MAD third party liability unit is
responsible for monitoring and collecting payments received from liable third
parties. See 8.302.3 NMAC.
[8.200.430.17 NMAC -
Rp, 8.200.430.17 NMAC, 1/1/2014; A, 10/15/2014; A, 11/1/2024]
8.200.430.18 REPORTING REQUIREMENTS: A medicaid eligible recipient is required to report certain
changes which might affect 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 HCA. The following changes must be reported to
ISD:
A. Living arrangements or change of address:
Any change in where an eligible
recipient lives or gets their 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 either or both the assistance unit and budget group.
C. Enumeration: Any new social security number must be reported.
D. Income: Except
for continuous eligibility in 8.200.400 NMAC any increase or decrease in the
amount of income or change in the source of income must be reported.
E. Resource: Resources only apply to non-modified adjusted
gross income (MAGI) medicaid categories. Any change in what an eligible recipient owns
must be reported. This includes any
property the eligible recipient owns or has interest in, cash on hand, money in
banks or credit unions, stocks, bonds, life insurance policies or any other
item of value.
[8.200.430.18 NMAC -
Rp, 8.200.430.18 NMAC, 1/1/2014; A, 2/14/2014; 8.200.430.18 NMAC - Rn & A,
8.200.430.19 NMAC, 10/15/2014; A, 10/1/2017; A, 11/1/2024]
8.200.430.19 MAD ESTATE RECOVERY: HCA is
mandated to seek recovery from the estates of certain individuals up to the
amount of medical assistance payments made by the HCA on behalf of the
individual. See Social Security Act
Section 1917 (42 USC 1396p(b) and Section 27-2A-1 et seq., NMSA 1978
"Medicaid Estate Recovery Act").
A. Definitions used in MAD estate recovery:
(1) Authorized
representative: The individual designated to represent and act on the eligible
recipient’s behalf. The eligible
recipient or authorized representative must provide formal documentation authorizing
the named individual or individuals to access the identified case information
for a specified purpose and time frame. An
authorized representative may be an attorney representing a person or
household, a person acting under the authority of a valid power of attorney, a
guardian, or any other individual or individuals designated in writing by the
member.
(2) Estate:
Real and personal property and other assets of an individual subject to probate
or administration pursuant to the New Mexico Uniform Probate Code.
(3) Medical
assistance: Amounts paid by HCA for long term care services including related
hospital and prescription drug services.
B. Basis for
defining the group: A MAP eligible
recipient who was 55 years of age or older when medical assistance payments
were made on their behalf for nursing facilities services, home and community
based services, and related hospital and prescription drug services are subject
to estate recovery.
C. The following exemptions apply to estate
recovery:
(1) Qualified
medicare beneficiaries, specified low-income
beneficiaries, qualifying individuals, and qualified disabled and working
individuals, are exempt from estate recovery for the receipt of hospital and
prescription drug services unless they are concurrently in a MAP nursing
facility category of eligibility or on a home and community based services
waiver; this provision applies to medicare
cost-sharing benefits (i.e., Part A and Part B premiums, deductibles,
coinsurance, and co-payments) paid under the medicare
savings programs.
(2) Certain
income, resources, and property are exempted from MAD estate recovery for
native Americans:
(a) interest
in and income derived from tribal land and other resources held in trust status
and judgment funds from the Indian claims commission and the United States
claims court;
(b) ownership
interest in trust or non-trust property, including real property and
improvements;
(i) located on a reservation or near a
reservation as designated and approved by the bureau of Indian affairs of the
U.S, department of interior; or
(ii) for
any federally-recognized tribe located within the most recent boundaries of a
prior federal reservation; and
(iii) protection
of non-trust property described in Subparagraphs (a) and (b) is limited to
circumstances when it passes from a native American to one or more relatives,
including native Americans not enrolled as members of a tribe and non-native
Americans such as a spouse and step-children, that their culture would
nevertheless protect as family members; to a tribe or tribal organization; or
to one or more native Americans;
(c) income
left as a remainder in an estate derived from property protected in Paragraph
(2) above, that was either collected by a native American, or by a tribe or
tribal organization and distributed to native Americans that the individual can
clearly trace the income as coming from the protected property;
(d) ownership
interests left as a remainder in an estate in rents, leases, royalties, or
usage rights related to natural resources resulting from the exercise of
federally-protected rights, and income either collected by a native American,
or by a tribe or tribal organization and distributed to native Americans
derived from these sources as long as the individual can clearly trace the
ownership interest as coming from protected sources; and
(e) ownership
interest in or usage of rights to items, not covered by Subparagraphs (a)
through (d) above, that have unique religious, spiritual, traditional, or
cultural significance or rights that support subsistence or a traditional
lifestyle according to applicable tribal law or custom.
(3) Effective July 1, 2024, the HCA
does not seek payment from an achieving a better life experience (ABLE) account
or its proceeds for medicaid benefits provided to the
beneficiary of the account.
D. Recovery process: Recovery from an eligible recipient's estate
will be made only after the death of the eligible recipient's surviving spouse,
if any, and only at a time that the eligible recipient does not have surviving
child who is less than 21 years of age, blind, or who meet the SSA definition
of disability.
(1) Estate
recovery is limited to payments for applicable services received on or after
October 1, 1993; except that recovery also is permitted for pre-October 1993
payments for nursing facility services received by a MAP recipient who was 65
years of age or older when such nursing facility services were received.
(2) A
recovery notice will be mailed to the authorized representative or next of kin
upon the eligible recipient’s death informing them about the amount of claim
against the estate and provide information on hardship waivers and hearing
rights.
(3) It
is the family or authorized representative’s responsibility to report the
eligible recipient’s date of death to the ISD office within 10 calendar days
after the date of death.
E. Eligible recipient rights and
responsibilities:
(1) At
the time of application or re-certification, the authorized representative must
be identified or confirmed by the applicant or eligible recipient or their
designee.
(2) Information
explaining estate recovery will be furnished to the applicant or eligible
recipient, their personal representative, or designee during the application or
re-certification process. Upon the death of the MAP eligible recipient,
a notice of intent to collect (recovery) letter will be mailed to the eligible
recipient’s personal representative with the total amount of claims paid by MAD
on behalf of the eligible recipient. The
authorized representative must acknowledge receipt of this letter in the manner
prescribed in the letter within 30 calendar days of the date on the letter.
(3) During
the application or re-certification process for] MAP eligibility, the local
county ISD office
will identify the assets of an applicant or the eligible recipient. This includes all real and personal property
which belongs in whole or in part to the applicant or eligible recipient and
the current fair market value of each asset.
Any known encumbrances on the asset should be identified at this time by
the applicant or the eligible recipient or their authorized representative.
(4) MAD,
or its designee, will send notice of recovery to the probate court, when
applicable, and to the eligible recipient’s authorized representative or
successor in interest. The notice will
contain the following information:
(a) statement
describing the action MAD, or its designee, intends to
take;
(b) reasons
for the intended action;
(c) statutory
authority for the action;
(d) amount
to be recovered;
(e) opportunity
to apply for the undue hardship waiver;
(f) procedures
for applying for a hardship waiver and the relevant timeframes involved;
(g) explanation
of the eligible recipient’s personal representative's right to request a HCA administrative hearing; and
(h) the
method by which an affected person may obtain a HCA
administrative hearing and the applicable timeframes involved.
(5) Once
notified by MAD, or its designee, of the decision to seek recovery, it is the
responsibility of the eligible recipient's authorized representative or
successor in interest to notify other individuals who would be affected by the
proposed recovery.
(6) The
authorized representative will:
(a) remit
the amount of medical assistance payments to HCA or its designee;
(b) apply
for an undue hardship waiver; (see Paragraph (2) of Subsection F below); or
(c) request
an administrative hearing.
F. Waivers:
(1) For
a general waiver, HCA may compromise, settle, or waive recovery pursuant to the
Medicaid Estate Recovery Act if it deems that such action is in the best
interest of the state or federal government.
(2) Hardship
provision: HCA, or its designee, may waive recovery because recovery would work
an undue hardship on the heirs. The
following are deemed to be causes for hardship:
(a) the
deceased recipient's heir would become eligible for a needs-based assistance
program such as medicaid or temporary assistance to
needy families (TANF) or be put at risk of serious deprivation without the
receipt of the proceeds of the estate;
(b) the
deceased eligible recipient's heir would be able to discontinue reliance on a
needs-based program (such as medicaid or TANF) if they
received the inheritance from the estate;
(c) the
deceased recipient’s assets which are subject to recovery are the sole income
source for the heir;
(d) the
homestead is worth 50 percent or less than the average price of a home in the
county where the home is located based on census data compared to the property
tax value of the home; or
(e) there
are other compelling circumstances as determined by HCA or its designee.
[8.200.430.19 NMAC -
N, 1/1/2014; 8.200.430.19 NMAC - Rn & A, 8.200.430.20 NMAC, 10/15/2014; A,
11/1/2024]
8.200.430.20 [RESERVED]
[8.200.430.20 NMAC - N, 1/1/2014; Repealed, 10/15/2014]
HISTORY OF
8.200.430 NMAC: The material
in this part was derived from that previously filed with the State Records
Center:
8 NMAC 4.MAD.430,
Recipient Policies, Recipient Rights and Responsibilities, filed 12/30/1994.
History of
Repealed Material:
8.200.430 NMAC,
Recipient Rights and Responsibilities, filed 12/13/2000 - Repealed effective 1/1/2014.