TITLE 8 SOCIAL SERVICES
CHAPTER 243 MEDICAID ELIGIBILITY - WORKING DISABLED
INDIVIDUALS (WDI) (CATEGORY 043)
PART 400 RECIPIENT POLICIES
8.243.400.1 ISSUING AGENCY: New Mexico
Health Care Authority.
[8.243.400.1 NMAC - Rp, 8.243.400.1
NMAC, 1/1/2019;
A, 7/1/2024]
8.243.400.2 SCOPE: This rule
applies to the general public.
[8.243.400.2 NMAC - Rp,
8.243.400.2 NMAC, 1/1/2019]
8.243.400.3 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 by the state human
services department pursuant to state statute.
See 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.
[8.243.400.3 NMAC - Rp, 8.243.400.3 NMAC, 1/1/2019; A, 7/1/2024]
8.243.400.4 DURATION: Permanent.
[8.243.400.4 NMAC - Rp,
8.243.400.4 NMAC, 1/1/2019]
8.243.400.5 EFFECTIVE DATE: January 1,
2019, or upon a later approval date by the federal centers for medicare and medicaid services
(CMS), unless a later date is cited at the end of the section.
[8.243.400.5 NMAC - Rp,
8.243.400.5 NMAC, 1/1/2019]
8.243.400.6 OBJECTIVE: The objective
of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.243.400.6 NMAC - Rp,
8.243.400.6 NMAC, 1/1/2019]
8.243.400.7 DEFINITIONS: [RESERVED]
8.243.400.8 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.
[8.243.400.8 NMAC - Rp,
8.243.400.8 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.9 WORKING DISABLED INDIVIDUALS (WDI) -
CATEGORY 043: The working disabled individuals program
covers:
A. disabled individuals who are
employed; or
B. disabled individuals who have lost
eligibility for supplemental security income (SSI) and medicaid
due to initial receipt of social security disability insurance ( SSDI) and who
are not yet qualified for medicare; this group is
referred to as “medigap”; once the medigap individual begins receiving medicare, they must become employed, as defined in
Paragraph (1) of Subsection C of 8.243.400.10 NMAC, to retain their eligibility
for WDI.
[8.243.400.9 NMAC - Rp,
8.243.400.9 NMAC, 1/1/2019]
8.243.400.10 BASIS
FOR DEFINING THE GROUP: Individuals eligible for medicaid coverage under the working disabled individuals
program (WDI) must meet the following requirements:
A. must meet the social security
administration disability criteria without regard to “substantial gainful
activity”, and
B. must have a recent attachment to the
workforce.
C. Recent attachment to workforce
defined: Medicaid for the working disabled
individuals defines recent attachment to the workforce as either:
(1) having enough gross earnings in a
quarter to meet social security administration’s definition of a qualifying
quarter, see 8.200.520.20 NMAC; or
(2) having lost SSI and medicaid due to the initial receipt of SSDI benefits, and being within the 24-month waiting period for medicare.
[8.243.400.10 NMAC - Rp,
8.243.400.10 NMAC, 1/1/2019]
8.243.400.11 GENERAL RECIPIENT REQUIREMENTS: [RESERVED]
8.243.400.12 ENUMERATION: To be eligible
an individual must report their social security account number(s) to the human
services department (HSD). If an
individual does not have a valid social security number, the individual must
apply for one as a condition of medicaid
eligibility. Applications for social
security numbers can be made by completing an application form,
and providing proof of application to local Income support division
(ISD) offices.
[8.243.400.12 NMAC - Rp,
8.243.400.12 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.13 CITIZENSHIP: To be eligible for medicaid,
an individual must be:
A. a citizen of the United States; or
B. a non-citizen who entered the United
States prior to August 22, 1996, as one of the classes of non-citizens described
in Subsection A of 8.200.410.11 NMAC, or a non-citizen who entered the United
States as a qualified non-citizen on or after August 22, 1996, and who has met
the five-year bar, or are exempt as listed in Subsection B of 8.200.410.11 NMAC.
C. Refer to 8.200.410.11 NMAC.
[8.243.400.13 NMAC - Rp,
8.243.400.13 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.14 RESIDENCE: To be eligible for medicaid,
individuals must be living in New Mexico on the date of application or final
determination of eligibility and have demonstrated intent to remain in the
state.
A. Establishing residence: Residence
in New Mexico is established by living in the state and carrying out the types
of activities normally indicating residency, such as occupying a home,
enrolling child(ren) in school, getting a state driver's license, or renting a
post office box. An individual who is
homeless is considered to have met the residence requirements if the individual
intends to remain in the state.
B. Recipients receiving benefits
out-of-state: Individuals who
receive medical assistance in another state are considered residents of that
state until the ISD staff receives verification from the other state agency
indicating that it has been notified by an individual of the abandonment of
residence in that state.
C. Abandonment: Residence is not abandoned by temporary
absences. Temporary absences occur when
recipients leave New Mexico for specific purposes with time-limited goals.
Residence is considered abandoned when any of the following occurs:
(1) the individual leaves New Mexico and
indicates that they intend to establish residence in another state;
(2) the individual leaves New Mexico for
no specific purpose with no clear intention of returning;
(3) the individual leaves New Mexico and
applies for financial, food or medical assistance in another state.
[8.243.400.14 NMAC - Rp,
8.243.400.14 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.15 NON-CONCURRENT RECEIPT OF ASSISTANCE: The individual
may not be receiving assistance in another medicaid
category with the exception of the qualified medicare beneficiaries (QMB) and specified low income medicare beneficiaries (SLIMB) programs. ISD staff will look at other categories of
eligibility and make the appropriate eligibility determination, or referrals.
[8.243.400.15 NMAC - Rp,
8.243.400.15 NMAC, 1/1/2019]
8.243.400.16 AGE: The individual must be 18 years
of age or older.
[8.243.400.16 NMAC - Rp,
8.243.400.16 NMAC, 1/1/2019]
8.243.400.17 DISABILITY: The individual
must meet social security administration’s disability or blindness criteria,
without regard to “substantial gainful activity”.
[8.243.400.17 NMAC - Rp,
8.243.400.17 NMAC, 1/1/2019]
8.243.400.18 RECIPIENT RIGHTS AND RESPONSIBILITIES: The individual
is responsible for establishing their eligibility for medicaid. As part of this responsibility, the
individual 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. The individual must also grant
the human services department (HSD) permission to contact other persons,
agencies or sources of information which are necessary to establish
eligibility.
[8.243.400.18 NMAC - Rp,
8.243.400.18 NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.19 ASSIGNMENT
OF MEDICAL SUPPORT: The individual must assign their right
to medical support or other third party payments to the state.
A. Assignment of medical support rights
occurs through the application for medicaid benefits.
B. Medicaid is not denied to an
otherwise eligible individual solely because they cannot legally assign their
own medical support rights and the party who is legally able to assign those
rights refuses to assign or cooperate, as required by law.
[8.243.400.19 NMAC - Rp, 8.243.400.19
NMAC, 1/1/2019; A, 1/1/2022]
8.243.400.20 REPORTING
REQUIREMENTS: An applicant/recipient
is responsible to report changes affecting eligibility by the end of the
calendar quarter in which the change took place.
[8.243.400.20 NMAC - Rp,
8.243.400.20 NMAC, 1/1/2019]
HISTORY OF 8.243.400 NMAC: [RESERVED]
History of Repealed
Material:
8.243.400 NMAC - Recipient
Policies, filed 12/13/2000 - Repealed effective 1/1/2019.