TITLE 8 SOCIAL SERVICES

CHAPTER 280 MEDICAID ELIGIBILITY - PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)

PART 400 RECIPIENT POLICIES

8.280.400.1 ISSUING AGENCY: New Mexico Health Care Authority.

[8.280.400.1 NMAC - Rp, 8.280.400.1 NMAC, 1/1/2019; A,7/1/2024; A, 7/1/2024

8.280.400.2 SCOPE: The rule applies to the general public.

[8.280.400.2 NMAC - Rp, 8.280.400.2 NMAC, 1/1/2019]

8.280.400.3 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.

[8.280.400.3 NMAC - Rp, 8.280.400.3 NMAC, 1/1/2019; A,7/1/2024; A, 7/1/2024]

8.280.400.4 DURATION: Permanent.

[8.280.400.4 NMAC - Rp, 8.280.400.4 NMAC, 1/1/2019]

8.280.400.5 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.

[8.280.400.5 NMAC - Rp, 8.280.400.5 NMAC, 1/1/2019]

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

[8.280.400.6 NMAC - Rp, 8.280.400.6 NMAC, 1/1/2019]

8.280.400.7 DEFINITIONS: [RESERVED]

8.280.400.8 MISSION STATEMENT: 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.

[8.280.400.8 NMAC - N, 2/1/2021]

8.280.400.9 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) - CATEGORIES 081, 083, AND 084: Certain populations meeting financial, non-financial, and medical criteria can receive acute and long-term care services in the community. These services are funded by medicaid on a capitated basis.

[8.280.400.9 NMAC - Rp, 8.280.400.9 NMAC, 1/1/2019]

8.280.400.10 BASIS FOR DEFINING THE GROUP: Recipients and eligible applicants must live in certain designated zip codes within New Mexico. A PACE recipient cannot concurrently receive other medicaid home and community-based services. A PACE recipient may be placed in a qualifying nursing facility upon a medical doctor's orders and continue to participate in PACE. Upon disenrollment from PACE, a former PACE recipient may receive institutional care (IC) medicaid services as long as the individual meets all IC medicaid eligibility requirements. PACE recipients can concurrently receive the qualified medicare beneficiaries program (QMB), the specified low income medicare beneficiaries program (SLIMB), or supplemental security income (SSI). For PACE applicants/recipients who receive SSI benefits no further verification of income, resources, citizenship, age, disability, or blindness is required.

[8.280.400.10 NMAC - Rp, 8.280.400.10 NMAC, 1/1/2019; A, 2/1/2021]

8.280.400.11 APPLICANT AND RECIPIENT REQUIREMENTS: Applicants must live within the designated PACE service area and meet all of the criteria listed below at the time of application and enrollment.

A. Applicants must be 55 years of age or older. Applicants/recipients must be determined blind or disabled if under the age of 65 years.

(1) To be considered blind, an applicant/recipient must have central visual acuity of 20/200 or less with corrective lenses or must be considered blind for practical purposes.

(2) To be considered disabled, an applicant/recipient must be unable to engage in any substantial gainful activity, because of any medically determinable physical, developmental, or mental impairment which has lasted, or is expected to last, for a continuous period of at least 12 months.

(3) If a determination of blindness or disability has not been made, the income support division worker will submit medical reports to the disability determination unit.

B. Level of care requirements must be met in addition to all other requirements. An applicant or recipient must be eligible for institutional nursing facility level of care as determined by the medical assistance division (MAD) utilization review contractor. An institutional level of care must be recommended for the applicant or recipient by a PACE physician licensed to practice medicine or osteopathy in the state of New Mexico. Institutions are defined as acute care hospitals, nursing facilities (either high NF or low NF as defined by medicaid regulations) and intermediate care facilities for individuals with intellectual disabilities (ICF/IID). Level of care determinations are performed by the MAD utilization review contractor. Level of care for approved recipients will be determined on an annual basis.

C. An interview is not required in accordance with 8.281.400.11 NMAC.

D. Upon enrollment, applicants must be able to live in a community setting without jeopardizing their individual health and safety. The ability to live safely in the home and community is determined by the PACE organization’s interdisciplinary team.

[8.280.400.11 NMAC - Rp, 8.280.400.11 NMAC, 1/1/2019; A, 2/1/2021, A, 1/1/2022]

8.280.400.12 RECIPIENT RIGHTS AND RESPONSIBILITIES: Applicants and recipients are responsible for establishing eligibility for medicaid. As part of this responsibility, the applicant or 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.

[8.280.400.12 NMAC - Rp, 8.280.400.12 NMAC, 1/1/2019; A, 2/1/2021]

8.280.400.13 REPORTING REQUIREMENTS: All changes that may affect eligibility must be reported within 10 calendar days of the date of the change in accordance with 8.200.430.18 NMAC.

[8.280.400.13 NMAC - Rp, 8.280.400.13 NMAC, 1/1/2019]

HISTORY OF 8.280.400 NMAC:

History of Repealed Material:

8 NMAC 4.PAC.400, Recipient Policies, filed 1/20/1998 - Repealed effective 12/1/2006.

8.280.400 NMAC - Recipient Policies, filed 11/15/2006 - Repealed effective 1/1/2019.