TITLE 8 SOCIAL SERVICES
CHAPTER 248 MEDICAID ELIGIBILITY - MEDICARE DRUG
COVERAGE (CATEGORY 048)
PART 600 BENEFIT
DESCRIPTION
8.248.600.1 ISSUING AGENCY: New Mexico Health
Care Authority.
[8.248.600.1
NMAC - Rp 8.248.600.1 NMAC, 7/1/2024]
8.248.600.2 SCOPE: The rule
applies to the general public.
[8.248.600.2
NMAC - Rp 8.248.600.2NMAC, 7/1/2024]
8.248.600.3 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 27-2-12 et. seq.NMSA 1978 ( Repl. Pamp.
1991). The legal basis for the
low-income subsidy (LIS) program is the Medicare Prescription Drug, Improvement
and Modernization Act of 2003 (MMA), Public Law 108-173. 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.
[8.248.600.3
NMAC - Rp 8.248.600.3NMAC, 7/1/2024]
8.248.600.4 DURATION: Permanent.
[8.248.600.4
NMAC - Rp 8.248.600.4NMAC, 7/1/2024]
8.248.600.5 EFFECTIVE DATE: July 1, 2024,
unless a later date is cited at the end of a section.
[8.248.600.5
NMAC - Rp 8.248.600.5NMAC, 7/1/2024]
8.248.600.6 OBJECTIVE: The objective
of these regulations is to provide eligibility policy and procedures for the medicare part D - low income subsidy program.
[8.248.600.6
NMAC - Rp 8.248.600.6NMAC, 7/1/2024]
8.248.600.7 DEFINITIONS: [RESERVED]
8.248.600.8 [RESERVED]
8.248.600.9 GENERAL BENEFIT DESCRIPTION: An individual
or couple who is determined eligible for the low income subsidy (LIS) under
part D of medicare, is eligible for financial
assistance with the monthly premium, the yearly deductible, the
per-prescription co-payment, and continuous coverage with no gap prior to
reaching $3,600 in out-of-pocket spending.
The financial assistance may be full or partial depending on the income,
family size and resources of the beneficiary.
[8.248.600.9
NMAC - Rp 8.248.600.9NMAC, 7/1/2024]
8.248.600.10 BENEFIT DETERMINATION: Completed
applications must be acted upon and notice of approval, denial, or delay
sent out within 45 days of the date of application. The applicant will have time limits explained
and be informed of the date by which the application should be processed.
[8.248.600.10
NMAC - Rp 8.248.600.10NMAC, 7/1/2024]
8.248.600.11 INITIAL BENEFITS: Eligibility is
always prospective and begins the month of application, but not earlier than
January 1, 2006. When an eligibility
determination is made, notice of the approval or denial is sent to the
individual. If the application is
denied, the notice shall include reason for denial and the applicant's right to
request a fair hearing.
[8.248.600.11
NMAC - Rp 8.248.600.11NMAC, 7/1/2024]
8.248.600.12 ONGOING BENEFITS: The
applicant/recipient is responsible to report changes affecting eligibility
within 10 days of when the change took place.
A re-determination of eligibility is made every 12 months. If a LIS recipient/applicant becomes eligible
for certain medicaid categories; SSI, QMB, SLIMB,
QI-1, WDI, IC, and HCBW, they will still be eligible for LIS. CMS will notify the beneficiary that they are
now deemed eligible, because of categorical relatedness and will take over the
re-determination of eligibility on a yearly basis. A change notice will be sent to the LIS
recipient. For the year 2006, all
certification periods will end December 31, 2006. Effective January 1, 2007, the certification
period will be 12 months from the month of application or re-certification.
[8.248.600.12
NMAC - Rp 8.248.600.12NMAC, 7/1/2024]
8.248.600.13 RETROACTIVE BENEFIT COVERAGE: There is no
three month retroactive LIS coverage under this program. The subsidy is effective the beginning of the
month of application or January 1, 2006, whichever is later.
[8.248.600.13
NMAC - Rp 8.248.600.13NMAC, 7/1/2024]
HISTORY OF 8.248.600 NMAC: [RESERVED]
History of Repealed Material: 8.248.600 NMAC - Benefit Description (filed
1/13/2006) Repealed effective 7/1/2024.
Other: 8.248.600
NMAC - Benefit Description
(filed 1/13/2006) Replaced by 8.248.600 NMAC - Benefit Description effective 7/1/2024.