TITLE 8 SOCIAL SERVICES
CHAPTER 240 MEDICAID ELIGIBILITY - QUALIFIED MEDICARE
BENEFICIARIES (QMB) (CATEGORY 040)
PART 400 RECIPIENT POLICIES
8.240.400.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.240.400.1 NMAC - Rp 8.240.400.1 NMAC, 7/1/2024]
8.240.400.2 SCOPE: The rule applies to the general public.
[8.240.400.2 NMAC - Rp 8.240.400.2 NMAC, 7/1/2024]
8.240.400.3 STATUTORY AUTHORITY: The New Mexico medicaid program is administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act, as amended, and by the state health care authority pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978 (Repl. Pamp. 1991). 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.
[8.240.400.3 NMAC - Rp 8.240.400.3 NMAC, 7/1/2024]
8.240.400.4 DURATION: Permanent.
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8.240.400.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.
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8.240.400.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.
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8.240.400.7 DEFINITIONS: [RESERVED]
8.240.400.8 [RESERVED]
8.240.400.9 QUALIFIED MEDICARE BENEFICIARIES (QMB) - CATEGORY 040: To be eligible for the qualified medicare beneficiaries program (QMB), an applicant/recipient must be covered by medicare part A. Medicare part A is a free entitlement to social security beneficiaries who are 65 years of age or older or who have received social security disability payments for 24 months. Fully or currently insured workers, or their dependents, who have end-stage renal disease are also covered under medicare. Most applicants/recipients 65 years of age or older who do not receive free medicare part A can voluntarily enroll for hospital insurance coverage, with payment of a monthly premium. Voluntary enrollees must also enroll for supplementary medical insurance, medicare part B, and pay that premium, as well.
[8.240.400.9 NMAC - Rp 8.240.400.9 NMAC, 7/1/2024]
8.240.400.10 BASIS FOR DEFINING THE GROUP: Applicants/recipients eligible for medicaid coverage under any other category may be eligible for coverage under QMB. QMB eligibility affords two advantages when an applicant/recipient is already eligible for medicaid:
A. medicare premium part A is payable by medicaid; and
B. medicaid receives federal matching funds for purchase of medicare part B.
[8.240.400.10 NMAC - Rp 8.240.400.10 NMAC, 7/1/2024]
8.240.400.11 GENERAL RECIPIENT REQUIREMENTS: [RESERVE]
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8.240.400.12 ENUMERATION: Applicants/recipients must furnish their social security account number(s). QMB eligibility is denied or terminated if applicants/recipients fail to furnish their social security numbers.
[8.240.400.12 NMAC - Rp 8.240.400.12 NMAC, 7/1/2024]
8.240.400.13 CITIZENSHIP:
A. Refer to medical assistance program manual 8.200.410.11 NMAC.
B. Verification of citizenship: Citizenship determinations rendered by the social security administration (SSA) for SSI are final.
(1) Documentation of citizenship: Primary documentation of citizenship is a birth certificate. Secondary documentation includes:
(a) certificate of naturalization;
(b) citizenship certificate;
(c) other resident identification documents issued by the United States immigration and naturalization service, such as:
(i) U.S. passport issued by the U.S. state department;
(ii) consular report of birth;
(iii) certification of birth issued by the U.S. state department, proof of marriage to a U.S. citizen before September 2, 1922, or a card of identity and registration of a U.S. citizen; or
(iv) official communication from an American foreign service post indicating that an applicant/recipient is registered as a United States citizen.
(2) Declaration of citizenship, nationality, or immigration status: As a condition of eligibility, medicaid requires a declaration by the applicant/recipient or by another person on behalf of a child or an applicant/recipient who is mentally incapacitated, which specifies whether the applicant/recipient is a citizen or national of the United States. If not, the declaration must state that the applicant/recipient is in satisfactory immigration status. Eligibility is not denied solely because an applicant/recipient cannot legally sign the declaration and the individual who is legally able to do so refuses to sign on the applicant/recipient’s behalf or to cooperate, as required.
[8.240.400.13 NMAC - Rp 8.240.400.13 NMAC, 7/1/2024]
8.240.400.14 RESIDENCE: An applicant/recipient must be physically present in New Mexico on the date of application or final determination of eligibility and have demonstrated intent to remain in the state. If the applicant/recipient does not have the present mental capacity to declare intent, the parent, guardian or adult child can assume responsibility for a declaration of intent. If there is no guardian or relative to assume responsibility for a declaration of intent, the state where the applicant/recipient is living is recognized as the state of residence. A temporary absence from the state does not prevent eligibility. A temporary absence exists if an applicant/recipient leaves the state for a specific purpose with a time-limited goal and intends to return to New Mexico when the purpose is accomplished.
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8.240.400.15 NONCONCURRENT RECEIPT OF ASSISTANCE: A QMB applicant/recipient on buy-in in another state cannot be approved for QMB in New Mexico until the other state’s buy-in is terminated.
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8.240.400.16 SPECIAL RECIPIENT REQUIREMENTS: There is no special recipient requirements such as age or disability for QMB.
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8.240.400.17 RECIPIENT RIGHTS AND RESPONSIBILITIES: An applicant/recipient is responsible for establishing their eligibility for medicaid. As part of this responsibility, the applicant/recipient must provide required information and documents or take the actions necessary to establish eligibility. Failure to do so must result in a decision that eligibility does not exist. An applicant/recipient must also grant the HCA permission to contact other persons, agencies or sources of information which are necessary to establish eligibility.
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8.240.400.18 ASSIGNMENTS OF MEDICAL SUPPORT: Refer to medical assistance program manual Subsection F of 8.200.420.12 NMAC.
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8.240.400.19 REPORTING REQUIREMENTS: All medicaid recipients must report any change in their circumstances which can affect eligibility to the local income support division (ISD) office within 10 days of the change.
[8.240.400.19 NMAC - Rp 8.240.400.19 NMAC, 7/1/2024]
HISTORY OF 8.240.400 NMAC:
Pre-NMAC History: The material in this part was derived from that previously filed with the Commission of Public Records - State Records Center and Archives:
MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/7/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/31/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/29/1989.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/22/1990.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/4/1990.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 5/3/1991.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/30/1992.
MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/1994.
History of Repealed Material:
MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/1994 - Repealed effective 2/1/1995.
8.240.400 NMAC - Recipient Policies (filed 6/13/2003) Repealed effective 7/1/2024.
Other: 8.240.400 NMAC - Recipient Policies (filed 6/13/2003) Replaced by 8.240.400 NMAC - Recipient Policies, effective 7/1/2024.