TITLE 8 SOCIAL SERVICES

CHAPTER 250 MEDICAL ASSISTANCE PROGRAM ELIGIBILITY – QUALIFIED INDIVIDUALS WHOSE INCOME EXCEEDS QMB AND SLIMB

PART 400 RECIPIENT REQUIREMENTS

8.250.400.1 ISSUING AGENCY: New Mexico Health Care Authority.

[8.250.400.1 NMAC - Rp, 8.250.400.1 NMAC, 1/1/2014; A, 7/1/2024]

8.250.400.2 SCOPE: The rule applies to the general public.

[8.250.400.2 NMAC - Rp, 8.250.400.2 NMAC, 1/1/2014]

8.250.400.3 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. 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.

[8.250.400.3 NMAC - Rp, 8.250.400.3 NMAC, 1/1/2014 ; A, 7/1/2024]

8.250.400.4 DURATION: Permanent.

[8.250.400.4 NMAC - Rp, 8.250.400.4 NMAC, 1/1/2014]

8.250.400.5 EFFECTIVE DATE: January 1, 2014, unless a later date is cited at the end of a section.

[8.250.400.5 NMAC - Rp, 8.250.400.5 NMAC, 1/1/2014]

8.250.400.6 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, 8.200 NMAC, Medicaid Eligibility – General Recipient Policies Processes for establishing and maintaining medicaid eligibility are detailed in the income support division (ISD) general provisions, 8.100 NMAC, General Provisions for Public Assistance Programs.

[8.250.400.6 NMAC - Rp, 8.250.400.6 NMAC, 1/1/2014]

8.250.400.7 DEFINITIONS: [RESERVED]

8.250.400.8 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.

[8.250.400.8 NMAC - Rp, 8.250.400.8 NMAC, 1/1/2014; A, 1/1/2022]

8.250.400.9 QUALIFIED INDIVIDUALS 1 (QI1s) - CATEGORY 042: Medical assistance division (MAD) pays the monthly medicare Part B insurance premium for eligible recipients with income between one hundred and twenty percent and one hundred and thirty-five percent of the federal poverty level (FPL) who are not otherwise eligible for another medical assistance program category of eligibility (QI1s). A QI1 recipient must be covered by medicare Part A. The Part A insurance 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, with end-stage renal disease are also covered under medicare. Eligible recipients will be served on a first come, first served basis, contingent upon availability of federal funds. Eligibility will be offered to individuals on a yearly basis. After 1998, eligible recipients currently enrolled in the program will get the first opportunity to continue to receive benefits under this program.

[8.250.400.9 NMAC - Rp, 8.250.400.9 NMAC, 1/1/2014; A, 1/1/2022]

8.250.400.10 BASIS FOR DEFINING THE GROUP: QI1s are individuals who would be qualified medicare beneficiaries (QMB) but for the fact that their income exceeds the income levels established for QMB and specified low income medicare beneficiaries (SLIMB). Income eligibility for the QI1s is at least one hundred and twenty percent of the FPL, but less than one hundred thirty-five percent. The state of New Mexico (the state) will permit all individuals to apply for assistance during a calendar year beginning 1998. However, because of the capped allotments, the state shall limit the number of participants in QI1s selected in a calendar year so that the aggregate amount of benefits provided to such individuals in the calendar year is estimated not to exceed the state’s allocation for the fiscal year ending in that calendar year. The state shall select QI1s on a first-come, first-served basis (in the order in which they apply). For calendar years after 1998, the state shall give preference to individuals who were QI1s, QMBs, SLIMBs, or qualified disabled working individuals (QDWI) in the last month of the previous year and who continue to be or become QI1s.

[8.250.400.10 NMAC - Rp, 8.250.400.10 NMAC, 1/1/2014; A, 1/1/2022]

8.250.400.11 [RESERVED]

8.250.400.12 ENUMERATION: QI1 applicants or re-determining recipients must furnish their social security numbers (SSN). QI1 eligibility shall be denied or terminated for applicants or re-determining recipients who fail to furnish social security numbers.

[8.250.400.12 NMAC - Rp, 8.250.400.12 NMAC, 1/1/2014]

8.250.400.13 CITIZENSHIP:

A. Undocumented non-citizens cannot purchase medicare coverage and, therefore, are not eligible for QI1 benefits. To be eligible for QI1 an applicant or re-determining recipient must be one of the following:

(1) a citizen of the United States; or

(2) a non-citizen who entered the United States prior to August 22, 1996, as one of the classes of non-citizens described in 8.200.410 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 listed in 8.200.410 NMAC.

B. Verification of citizenship: Individuals entitled to or receiving medicare already meet citizenship and identity requirements.

[8.250.400.13 NMAC - Rp, 8.250.400.13 NMAC, 1/1/2014; A, 1/1/2022]

8.250.400.14 RESIDENCE: An individual must physically present in New Mexico on the date of his or her application or re-determination or on the eligibility determination date and intends to remain in the state. If the applicant or re-determining 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 in which the applicant or re-determining recipient is living is recognized as the state of residence. A temporary absence from the state does not preclude eligibility. A temporary absence is considered to exist when the eligible recipient leaves the state for a specific purpose with a time-limited goal, after the accomplishment of which the eligible recipient intends to return to New Mexico. Refer to 8.200.410.12 NMAC.

[8.250.400.14 NMAC - Rp, 8.250.400.14 NMAC, 1/1/2014]

8.250.400.15 NONCONCURRENT RECEIPT OF ASSISTANCE: An applicant or re-determining recipient is not eligible for Category 042 if he or she is eligible under another medical assistance category of eligibility or if receiving medicaid services from another state.

[8.250.400.15 NMAC - Rp, 8.250.400.15 NMAC, 1/1/2014]

8.250.400.16 SPECIAL RECIPIENT REQUIREMENTS: An applicant or re-determining recipient for QI1 eligibility must meet the specified age or disability requirements to be eligible for medicare Part A.

[8.250.400.16 NMAC - Rp, 8.250.400.16 NMAC, 1/1/2014]

8.250.400.17 RECIPIENT RIGHTS AND RESPONSIBILITIES: It is the responsibility of the applicant or re-determining recipient to provide the required information, documents or undertake the actions necessary for HSD to establish eligibility. The applicant or re-determining recipient must grant HSD permission to contact other persons, agencies or sources of information which are necessary in the establishment of eligibility. Failure of the applicant or re-determining recipient to provide or take action will result in a HSD action to deny eligibility.

[8.250.400.17 NMAC - Rp, 8.250.400.17 NMAC, 1/1/2014]

8.250.400.18 [RESERVED]

8.250.400.19 REPORTING REQUIREMENTS: An applicant, re-determining or eligible recipient must report any change in his or her circumstances which can affect his or her eligibility within 10 calendar days after the change to his or her local income support division (ISD) office. Refer to 8.200.430.19 NMAC.

[8.250.400.19 NMAC - Rp, 8.250.400.19 NMAC, 1/1/2014]

HISTORY OF 8.250.400 NMAC:

History of Repealed Material:

8.250.400 NMAC, Recipient Policies, filed 11/16/2009 - Repealed effective 1/1/2014.