TITLE 8 SOCIAL SERVICES
CHAPTER
281 MEDICAID ELIGIBILITY - INSTITUTIONAL
CARE (CATEGORIES 081, 083 and 084)
PART 600 BENEFIT DESCRIPTION
8.281.600.1 ISSUING AGENCY: New
Mexico Human Services Department.
[8.281.600.1 NMAC - Rp, 8.281.600.1 NMAC, 1/1/2019]
8.281.600.2 SCOPE: The
rule applies to the general public.
[8.281.600.2 NMAC - Rp, 8.281.600.2 NMAC, 1/1/2019]
8.281.600.3 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 human services department pursuant to state statute. See Section 27-2-12 et seq., NMSA 1978 (Repl. Pamp. 1991).
[8.281.600.3 NMAC - Rp, 8.281.600.3 NMAC, 1/1/2019]
8.281.600.4 DURATION:
Permanent.
[8.281.600.4 NMAC - Rp, 8.281.600.4 NMAC, 1/1/2019]
8.281.600.5 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.
[8.281.600.5 NMAC - Rp, 8.281.600.5 NMAC, 1/1/2019]
8.281.600.6 OBJECTIVE: The
objective of these regulations is to provide eligibility policy and procedures
for the medicaid program.
[8.281.600.6 NMAC - Rp, 8.281.600.6 NMAC, 1/1/2019]
8.281.600.7 DEFINITIONS: [RESERVED]
8.281.600.8 [RESERVED]
8.281.600.9 BENEFIT DESCRIPTION:
Applicant/recipient who is eligible for institutional care medicaid is eligible to receive the full range of medicaid-covered services, unless coverage is restricted
due to transfer of asset penalties.
[8.281.600.9 NMAC - Rp, 8.281.600.9 NMAC, 1/1/2019]
8.281.600.10 BENEFIT
DETERMINATION:
A. Application for institutional care medicaid
is made using the HSD 100 application.
Completed applications must be acted upon and notice of approval,
denial, or delay sent out within 45 days from the date of registration. The income support division (ISD) worker
explains time limits to the applicant and informs him or her of the date by
which the application should be processed.
B. Representatives applying on behalf of individuals: If a representative makes application on
behalf of an institutionalized individual, the representative is relied upon
for information. The ISD worker sends
all notices to the applicant/recipient in care of the representative. If the individual who makes an application is
an employee of the institution, the ISD worker contacts the applicant’s family
or other involved individuals. The ISD
worker focuses on the applicant/recipient’s current circumstances and on past
circumstances which may provide clues to existing or potential resources.
[8.281.600.10 NMAC -
Rp, 8.281.600.10 NMAC, 1/1/2019]
8.281.600.11 INITIAL BENEFITS:
A. For an applicant/recipient who loses supplemental
security income (SSI) eligibility after entering an institution, the
institutional care medicaid application date is the
first day of the month of SSI termination, or the month the application is
received by the ISD worker, whichever is earlier.
B. Notice of determination: Applicants eligible for
institutional care medicaid are notified of the
approval and advised of the amount, if any, of the medical care credit. Applicants who are ineligible are notified of
the denial and provided with an explanation of appeal rights.
[8.281.600.11 NMAC -
Rp, 8.281.600.11 NMAC, 1/1/2019]
8.281.600.12 ONGOING BENEFITS: A
complete redetermination of eligibility must be performed by the ISD worker for
each open case at least annually.
A. Regular reviews:
For each regular yearly review, the ISD worker must determine:
(1) whether medical care credit payments are up to date; an overdue
balance may indicate a change in circumstances that is unreported, particularly
where rental property is involved; and
(2) whether the deposit to the recipient’s personal fund is
consistently no more than the applicable personal needs allowance amount per
month; a larger deposit may indicate an increase in income that is unreported
or a previously unidentified source of income.
B. Level of care reviews are required to be completed at
least annually. Level of care
determinations are made by the utilization review contractor or a member’s
selected or assigned managed care organization.
[8.281.600.12 NMAC -
Rp, 8.281.600.12 NMAC, 1/1/2019]
8.281.600.13 RETROACTIVE BENEFIT COVERAGE: Up to
three months of retroactive medicaid coverage can be
furnished to applicants who have received medicaid-covered
services during the retroactive period and would have met applicable
eligibility criteria had they applied during the three months prior to the
month of application. Retroactive medicaid coverage is provided in accordance with
8.200.400.14 NMAC.
[8.281.600.13 NMAC -
Rp, 8.281.600.13 NMAC, 1/1/2019]
8.281.600.14 CHANGES IN ELIGIBILITY:
A. The following procedures apply when an institutional care
medicaid recipient leaves an institution:
(1) the recipient is notified in writing that his/her
eligibility for institutional care medicaid has
terminated;
(2) the institutional care medicaid case
is closed;
(3) the recipient is screened for other medicaid
program eligibility; or
(4) the recipient is referred to the social security
administration for determination of eligibility for SSI benefits if
appropriate; if a recipient dies in an institution, the case is closed the
following month.
B. Discharge status:
Discharge status continues after the utilization review (UR) contractor
determines that there is no medical necessity for a high nursing facility (NF)
or low NF placement. Discharge status
does not apply to an acute care placement.
After placement in discharge status, the recipient continues to be
eligible for institutional care medicaid since he/she
still requires institutional care.
(1) Abstract
submission: Discharge status requires a
new abstract be submitted at regular intervals. The institution must attach verification to
the abstract that adequate placement has been and is being sought.
(2) Case
closure: The ISD worker takes no action
to close a case until the recipient is actually discharged from the
institution. If the recipient is
transferred from high NF to low NF, medicaid coverage
is not interrupted, unless the recipient is ineligible for other reasons.
[8.281.600.14 NMAC -
Rp, 8.281.600.14 NMAC, 1/1/2019]
HISTORY OF
8.281.600 NMAC:
Pre-NMAC
History: The material in this part was
derived from that previously filed with the State Records Center:
ISD Rule 380.0000,
Medical Assistance for Persons Requiring Institutional Care, filed 12/29/1983.
ISD Rule 380.0000,
Medical Assistance for Persons Requiring Institutional Care, filed 8/11/1987.
MAD Rule 380.0000,
Medical Assistance for Persons Requiring Institutional Care, filed 2/5/1988.
MAD Rule 380.0000,
Medical Assistance for Persons Requiring Institutional Care, filed 2/25/1988.
MAD Rule 380.0000,
Medical Assistance for Persons Requiring Institutional Care, filed 6/1/1988.
MAD Rule 380.0000,
Medical Assistance for Persons Requiring Institutional Care, filed 1/31/1989.
MAD Rule 380.0000,
Medical Assistance for Persons Requiring Institutional Care, filed 6/21/1989.
MAD Rule 880.0000,
Medical Assistance for Persons Requiring Institutional Care, filed 3/21/1990.
MAD Rule 880,
Medical Assistance for Persons Requiring Institutional Care, filed 5/3/1991.
MAD Rule 880,
Medical Assistance for Persons Requiring Institutional Care, filed 6/12/1992.
MAD Rule 880,
Medical Assistance for Persons Requiring Institutional Care, filed 11/16/1994.
MAD Rule 882,
Resources - Medical Assistance for Persons Requiring Institutional Care, filed
3/9/1993.
MAD Rule 882,
Resources - Medical Assistance for Persons Requiring Institutional Care, filed
11/16/1994.
MAD Rule 882,
Resources, filed 12/29/1994.
MAD Rule 883, Income
- Medical Assistance for Persons Requiring Institutional Care, filed 3/18/1993.
MAD Rule 883, Income
- Medical Assistance for Persons Requiring Institutional Care, filed 11/16/1994.
MAD Rule 883,
Income, filed 12/29/1994.
MAD Rule 885,
Medical Care Credit, filed 11/16/1994.
MAD Rule 888,
Medicare Catastrophic Coverage Act of 1988 Regarding Transfers of Assets, filed
3/10/1994.
MAD Rule 888,
Transfers of Assets, filed 12/27/1994.
MAD Rule 889,
Spousal Impoverishment, filed 8/17/1992.
MAD Rule 889,
Spousal Impoverishment, filed 2/17/1994.
History of Repealed Material:
MAD Rule 880,
Medical Assistance for Persons Requiring Institutional Care, filed 11/16/1994 -
Repealed effective 2/1/1995.
MAD Rule 882,
Resources, filed 12/29/1994 - Repealed effective 2/1/1995.
MAD Rule 883, Income,
filed 12/29/1994 - Repealed effective 2/1/1995.
MAD Rule 885,
Medical Care Credit, filed 11/16/1994 - Repealed effective 2/1/1995.
MAD Rule 888,
Transfers of Assets, filed 12/27/1994 - Repealed effective 2/1/1995.
MAD Rule 889,
Spousal Impoverishment, filed 2/17/1994 - Repealed effective 2/1/1995.
8 NMAC 4.ICM.600,
Benefit Description, filed 12/30/1994 - Repealed effective 4/1/2009.
8.281.600 NMAC –
Benefit Description, filed 3/13/2009 - Repealed effective 1/1/2019.