TITLE 8 SOCIAL SERVICES

CHAPTER 240 MEDICAID ELIGIBILITY - QUALIFIED MEDICARE BENEFICIARIES (QMB) (CATEGORY 040)

PART 600 BENEFIT DESCRIPTION

8.240.600.1 ISSUING AGENCY: New Mexico Health Care Authority.

[8.240.600.1 NMAC - Rp, 8.240.600.1 NMAC, 7/1/2024]

8.240.600.2 SCOPE: The rule applies to the general public.

[8.240.600.2 NMAC - Rp, 8.240.600.2 NMAC, 7/1/2024]

8.240.600.3 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. 191991). 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.

[8.240.600.3 NMAC - Rp, 8.240.600.3 NMAC, 7/1/2024]

8.240.600.4 DURATION: Permanent.

[8.240.600.4 NMAC - Rp, 8.240.600.4 NMAC, 7/1/2024]

8.240.600.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at the end of a section.

[8.240.600.5 NMAC - Rp, 8.240.600.5 NMAC, 7/1/2024]

8.240.600.6 OBJECTIVE: The objective of these regulations is to provide eligibility policy and procedures for the medicaid program.

[8.240.600.6 NMAC - Rp, 8.240.600.6 NMAC, 7/1/2024]

8.240.600.7 DEFINITIONS: [RESERVED]

8.240.600.8 [RESERVED]

8.240.600.9 BENEFIT DESCRIPTION: For qualified medicare beneficiaries (QMB), medicaid covers payment of medicare premium amounts for Parts A and B and the coinsurance and deductibles on medicare-covered services. Medicaid does not pay for services which are not medicare benefits, services denied by medicare, or services furnished by providers who have not accepted medicare assignment. Reimbursement is made to providers of covered services and not directly to recipients.

[8.240.600.9 NMAC - Rp, 8.240.600.9 NMAC, 7/1/2024]

8.240.600.10 BENEFIT DETERMINATION: Application for QMB is made on the assistance application form. A separate application is not required if the recipient is receiving medicaid under another category. The income support specialist (ISS) must act on applications and send notice of action taken to the applicant within 45 days after the date of application. After the eligibility determination is made, notice of the approval or denial is sent to the applicant. If the application is denied, this notice includes the reason for the denial and an explanation of the recipient’s right to a hearing

[8.240.600.10 NMAC - Rp, 8.240.600.10 NMAC, 7/1/2024]

8.240.600.11 INITIAL BENEFITS: Eligibility begins the month after the month the case is approved. No retroactive coverage is available. Enrollment periods for medicare coverage: Individuals who are not entitled to free medicare Part A can purchase it. This is called “premium” or “conditional” Part A coverage. Applicants who are entitled to free medicare Part A may apply for QMB at any time. Enrollment for premium/conditional medicare Part A, is accepted by the social security administration (SSA) once a year, from January through March, with coverage starting in July. If a QMB applicant has an award letter or medicare card showing premium/conditional enrollment for July, the case can be approved in June with coverage beginning in July.

[8.240.600.11 NMAC - Rp, 8.240.600.11 NMAC, 7/1/2024]

8.240.600.12 ONGOING BENEFITS: A redetermination of eligibility conditions must be made at least every 12 months but no more frequently than every six months.

[8.240.600.12 NMAC - Rp, 8.240.600.12 NMAC, 7/1/2024]

8.240.600.13 RETROACTIVE BENEFITS: No retroactive medicaid benefits are available for applicants/recipients in this category.

[8.240.600.13 NMAC - Rp, 8.240.600.13 NMAC, 7/1/2024]

8.240.600.14 CHANGES IN ELIGIBILITY: A case is closed when the recipient becomes ineligible, with provision of advance notice. If a recipient dies, the case is closed the following month.

[8.240.600.14 NMAC - Rp, 8.240.600.14 NMAC, 7/1/2024]

HISTORY OF 8.240.600 NMAC:

Pre-NMAC History: The material in this part was derived from that previously filed with the 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.

8.240.600 NMAC - Benefit Description (filed 9/3/2013) Repealed effective 7/1/2024.

Other: 8.240.600 NMAC - Benefit Description (filed 9/3/2013) Replaced by 8.240.600 NMAC - Benefit Description effective 7/1/2024.